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Based on review of the hospital's Quality Plan, the Governing Board By-Laws, Governing Board meeting minutes, quality documents, and interviews, the hospital's Governing Board failed to be responsible for the conduct of the hospital with regard to patient suicide attempts by:

(A0043) the Governing Board failing to require processes were in place to ensure corrective actions to such potential negative events.

The cumulative effect of this systemic problems resulted in the inability of the HOSPITAL to be in compliance with the federal regulations for GOVERNING BODY which led to the potential for adverse patient events.



(A0043) Based on review of 2012 Quality Improvement Plan, Governing Board By-Laws, Minutes of the Governing Board meetings, quality documents, and interviews, it was determined that the Governing Board failed to be responsible for the conduct of the hospital events that had the potential for negative patient outcomes, and for the processes that were to ensure corrective actions of such potential negative events.

Findings include:

The hospital is governed by a "Network Governing Board" which as of the survey, and throughout 2012, governed 4 Southern Arizona hospitals.

The 2012 Quality Improvement Plan revealed, in part: "...II. A...The Carondelet Health Network Board of Directors has the ultimate authority and responsibility to ensure that leadership, medical staff, and associates demonstrate a consistent endeavor to deliver the highest quality patient care to communities served....3. The Board reviews summary quality, risk and safety data and specifies the frequency/detail of data collection processes...."

Amended and Restated By-Laws of Carondelet Health Network (The Governing Board) revealed, in part: "Corporation...8.1 The Board of Directors shall appoint and remove the President and Chief Executive Officer of the Corporation...8.2-f The President and Chief Executive Officer of the Corporation, in keeping with sound principles of management, is responsible to provide leadership in evaluating the performance of the Corporation..."

Patient #3 eloped from the locked psychiatric unit recreation area on 1/7/12 by climbing over the wall of this outdoor area. The quality document revealed the unit had decided the incident was a single event with no negative outcome. The Psychiatric Unit Director acknowledged, on interview 10/31/12, that the patient was a danger to self and others and the local police were notified and had been looking for him. The Psychiatric Unit Director stated that the patient had parked a car with a "not-noticeable" key taped to it and drove out of town, ending with an admission to a facility in another state.

No further process, analysis, tracking or trending was done. There was no forwarding of an outcome review to the Governing Board for their inclusion in the review of the event.

Patient #42 was found on 4/21/12 with a TV cord, from the TV in the 2nd floor Patient Day Room, around the patient's neck in a suicide attempt. Following the event the Psychiatric Unit had this 2nd floor Day Room TV mounted on the wall with no further follow up.

During the survey on 10/30/12, the TV in the first floor Patient Day Room was found to have multiple cords accessible to many patients. The Unit Management Staff, on interview 10/30/12, stated the hospital Safety Personnel had inspected the building for safety hazards following the 2nd floor TV cord event, including inspecting for cords that could be used for suicide attempt. Two other potential suicide dangers were observed during the 10/30/12 survey. A bed alarm was attached to an approximate 2 foot long nylon cord which had been clipped to a patient's bed and a sports bag with strap handles was left unsecured in the dining area.

No further process, analysis, tracking or trending was done. There was no forwarding of the event to the Governing Board for their inclusion in the outcome review of the event.

Patient #4 was admitted to the hospital's Emergency Department on 9/16/12 for Suicide Ideation and Homicide Ideation after having been found by law enforcement lying on a sidewalk with a razor blade and threatening harm. While in the Emergency Department the patient was found, by a housekeeper, attempting to strangle himself with the cord of a window blind in his Emergency Department room.

A quality document of the event was done by the patient's psychiatric therapist who wrote she removed the cord from the patient's neck and transferred the patient to a room without a blind that had a cord. The patient's psychiatric therapist, on interview on 10/31/12, acknowledged that she had cared for the patient, had seen the cord around his neck and removed it, and had observed red marks on the patient's neck caused by the cord.

The 2 quality documents had been reviewed by the Emergency Department's manager who stated, during an interview on 10/31/12, that his conclusion was that the incident of the cord had not happened. The Manager was asked if a blind cord was present in the Emergency Department patient's room and stated there was no cord. The Psychiatric Unit Director was asked, on 10/31/12, if the patient's Emergency Department room had a window blind cord present and acknowledged that it did.

No further process, analysis, tracking or trending was done. There was no forwarding of the event to the Governing Board for their inclusion in the outcome review of the event.

A review was conducted of the Board of Directors Meeting minutes for February 16, 2012, April 19, 2012, June 14, 2012, and September 12, 2012. Adverse events including suicide attempts did not appear in the Governing Board Meeting minutes.

The Network Vice President responsible for Quality stated that the department or unit managements were notified electronically of "events," then that department or unit management led a "work-up" of the event with an analysis. The Network Vice President for Quality stated that since April of 2012 the results of the event work-ups were to be reported to a Serious Event Review Team (SERT), who decided if the results should be reported to a hospital Clinical Excellence Committee (hospital CEC), who decided if the results should be reported to the Governing Board CEC, who decided if the results should be reported to the Governing Board.

The Network Vice President responsible for Quality produced, for the surveyors, an approximate 1 inch stack of quality reports of the 4 hospitals for the next Governing Board meeting. The Network Vice President for Quality stated this stack of quality reports, some aggregate data and some with data of each of the 4 hospitals listed, was an example of reports that the Governing Board members would receive.

The interview revealed no evidence of the Governing Board's involvement or lack of involvement in the review of adverse or potential adverse events other than to relate that the hospital staff quality process training, which had occurred between April of 2012 through the Summer of 2012 regarding adverse events, would need to be repeated.


12291

Based on observations, review of hospital documents, medical records, hospital policies and procedures and staff interviews, it was determined the hospital failed to:

A-0144: Ensure three behavioral health patients (Patients #3, 4, and 42) were provided care in a safe environment without access to items that could be used to harm themselves.

A-0174: Ensure one patient's physical restraints (Patient #17) were removed at the earliest possible time.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on reviews of clinical records, review of hospital policies and procedures and hospital internal records and staff interviews, it was determined for three patients (Patients #3, 4, and 42), the hospital failed to ensure the behavioral health patients were provided a safe environment without access to items that could be used to harm themselves.

Findings include:

The hospital's policy titled Environmental Safety Behavioral Health included the following: "In keeping with the commitment of Carondelet Behavioral Health to keep all patients, staff and visitors safe while in treatment at any of our facilities, Carondelet Behavioral Health staff will routinely check and screen patients and patient care environments for potentially dangerous items that may be located with patients or in the patient care environment...All Behavioral Health staff are responsible for ensuring patient safety. The team leader or Charge nurse assigns a Behavioral Health technician to document environmental rounds

The hospital's policy titled Suicide Risk Identification in Acute Care included the following: "Carondelet Health Network (CHN) is committed to the physical and mental health, safety, and welfare of all patients...This policy establishes guidelines for identifying patients who may be at risk for suicide and provides a process for implementing a plan of care to minimize suicide risks within CHN facilities. Environmental Controls A. Patient Room...Environmental controls are designed to prevent self-harm by limiting patient access to potentially harmful items and/or areas...All unnecessary equipment and supplies are removed from the patient room...Patient's belongings are searched for...belts, shoelaces, any type of string or rope (including dental floss)...."

-Patient #3 was admitted to the hospital's behavioral health unit, O'Reilly Care Center, on 1/05/2012 with diagnoses including "Bipolar Disorder, currently depressed, with psychotic features, polysubstance dependence (principally THC, cocaine)..." A psychiatry Progress Note dated 1/7/2012 at 10:45 a.m. included: "Pt. (with) severe mood swing hx (history)...Pt. also (with self-destructive behaviors including on unit...Pt (with) rage/anger/irritability...." The patient's height was documented at the time of admission to be 58 inches and his weight to be 122 pounds.

A Behavioral Health Technician (BHT) documented in the Behavioral Health Observation Checklist dated 1/7/2012 at 1:45 p.m. that the patient was on the phone. At 2 p.m., the BHT documented: "Yelling & tearful (after) call from S/O (significant other)...tore strip of sheet." At 2:45 p.m. and 3 p.m. the BHT documented the patient's mood was labile and his mood was flat and inappropriate. At 3:30 p.m. the patient was in the patio and at 3:45 p.m. the patient was "AWOL" (absent without leave).

The physician's documentation in the Discharge Summary dated 1/7/2012 included: "The patient at the time I saw him was reasonably cooperative. He has a very complex history. He was not psychotic. He was willing to accept treatment. Approximately 4 hours after seeing the patient, I received a call that he had AWOL'd through the outdoor area of the hospital...The unit had called the police and I contacted the father...The father also told me that he had been contacted by the patient's girlfriend and the patient's girlfriend had had a conversation with the patient in the afternoon which apparently did not go very well. The patient was very angry and told the girlfriend that he was going to get out of the hospital and he was going to kill himself...The patient has not as yet been found. If found, the patient will need to be petitioned acutely as a danger to self. He certainly meets all the criteria given that I am not trusting his ability to be a voluntary patient, at the present time, given what has happened."

The hospital conducted an investigation of the incident which revealed the patient was playing volleyball in the outside recreation unit of the behavioral health unit. The BHT monitoring the patients in the courtyard observed the patient jump over the southeast end of the wall. The BHT called out to the patient and encouraged him to stop which the patient did not respond to. The patient was not located. The hospital later learned on 1/8/2012 from the patient's father that the patient had a vehicle on hospital grounds with a key attached to the outside of the vehicle. The father also reported the patient's girlfriend called him (father) and told him, 'he was fine and going camping.'" On 1/23/2012, the hospital was provided clinical records from a hospital in California that included: "(Name of Patient #3)...drove himself from Arizona to Stanford 1/9/2012...On admission, pt was very disheveled, malodorous, intoxicated appearing, and disorganized...He drove from Arizona, stopping at the grand canyon and a 'Hopi reservation' along the way but he did not stop to sleep. 'Last night was the first time I slept since leaving Arizona'."

The hospital reported the Nurse Manager of the behavioral health unit and the hospital's safety office assessed the security of the recreation yard where the patient successfully scaled the wall. The report included: "The hard is completely enclosed by a 6' tall brick wall topped with 2 1/2-foot inward-curving wrought iron bars. The southeast corner has a metal mesh gate with a deadbolt lock...a physically fit male Behavioral Health Tech demonstrated how the patient climbed out of the yard. He placed one foot on the polished, slanted surface of the deadbolt lock...He levered his body upward so he could h=get his other foot wedged against the mortar line in the brick wall. He swung his foot off the deadbolt, grabbed the vertical bards, and 'walked' up the brick wall using the mortar lines as footholds. The maneuver was much like a rock climber scaling a cliff. Climbing out of the recreation yard by this route required an unusual degree of strength, agility and flexibility. No other patients have eloped in this matter. Increasing the height of the wall or adding metal mesh to the bars would probably have prevented this particular elopement. The resulting prison-like environment, however, would take a toll on patient morale and self-efficacy in this 100% voluntary patient population. The Director of Behavioral Health, Unit Manager, and Safety Officer determined that the recreation yard is sufficiently secure without any modifications."

Observation of the behavioral health unit's outside recreation area were made on 10/16/2012 at 10:30 a.m. with the Director of the Unit. The southeast corner of the wall where the patient eloped was pointed out to the surveyor. The bricks and mortar between the bricks on the east wall were rough in nature so that it would be possible to have enough traction to climb. The southeast corner metal gate had a deadbolt lock which extended approximately one-inch and could be used as leverage. The Director of the Unit reported during the tour and observation of the outside area that it would be too expensive to make the wall higher and they (hospital administration) had to make a decision on what kind of environment they wanted. She stated that because their patients are "voluntary," they wanted to create and maintain a "healing environment" and not a prison-like environment."

Patient #3 admitted himself to the hospital's behavioral health unit on 1/5/2012. On 1/7/2012 at 10:45 a.m., the physician described the patient with a history of severe mood swings, self-destructive behaviors including on the unit and having rage, anger and irritability. On 1/7/2012 at 2 p.m., the patient was yelling and tearful and tore a sheet. He continued to be labile with a flat and inappropriate affect. He was taken outside to the recreation area at 3:30 p.m. and then scaled the wall and eloped at approximately 3:45 p.m. The patient drove himself to a hospital in California where he was admitted on 1/9/2012 and remained there until discharged on 1/23/2012. At the time of his admission, he was described as "very disheveled, malodorous, and disorganized."

Hospital administration conducted an investigation of the incident and determined that because the behavioral health unit only admits patients on a "voluntary" basis, it was decided to maintain a "healing environment" and no modifications were going to be made. Observation of the outside recreation area on 10/16/2012 confirmed no modifications to the environment were made, and the risk of another patient elopement continued to exist.

-Patient #4 was taken to the ED on 9/16/2012 with suicidal ideation. (Refer to Tag A-0263 for specific details related to Patient #4). The patient was left unattended in a room with window blinds with a cord used to raise and lower the blinds. While alone, the patient wrapped the cord around his neck and was observed by a housekeeper who alerted staff. As of 10/30/2012, the room still had the window blinds with a cord.

-Patient #42 was admitted to the hospital's behavioral health unit with a primary diagnosis of depression on 4/6/2012 and was discharged on 7/3/2012. The physician's Discharge Documentation included the following: "Hospital Course: ...She went through periodic episodes of active self-destructive behavior. This was manifested by attempted strangulation with a power cord on several different occasions, she attempted to hang herself with a towel and attempted to inhale a wash cloth."

Nursing notes dated 4/21/2012 at 6:15 a.m. included: "Patient standing in upstairs TV room leaning against wall. Noise noted from TV room. When staff approached pt coughing, gasping (with) television cord around neck x 2 tight. Staff at pts side removing television cord around pts neck. Pt then assisted to chair still coughing. VSS (vital signs stable) 123/71 P (pulse) 135 R (respirations) 24..."

The incident was reported through the incident reporting system and investigated. The follow-up actions documented on 5/2/2012 included: "Cord to TV shorten. All of unit reviewed with Safety officer for potential safety issues. All in process of being addressed."

A tour was conducted of the hospital's behavioral health unit on 10/30/2012 at 12:30 p.m. The surveyors were accompanied by three members of nursing administration. During the tour, the following observations were made:

- The bottom of an unlocked wooden cabinet on the first floor patient dining room contained a large red bag with handle straps that could be used by a patient to harm themselves.
- There was a television on a large wooden cabinet in the corner of a room on the first floor. A surveyor was able to get behind the cabinet where there we are number of long cords with which a patient could use to harm themselves.
-There was a bed alarm with a detachable cord approximately 24 inches long clipped to the bed of an inpatient in Room 14. The cord could be used by a patient to harm themselves.

The behavioral health unit's inpatient census for 10/30/2012 was 15. Documentation on the census revealed there were two patients in Room 14 on that day. The patient in Bed 1 had a diagnosis of "Major Depression/ PTSD" (post traumatic stress disorder) and the patient in Bed 2 had a diagnosis of "Suicidal." There were four other inpatients with primary diagnoses of Major Depression, Suicidal Ideation, and/or post suicide attempt.

Based on observation, document review, and staff interview, it was determined the nursing staff did not remove Patient #17's restraints at the earliest possible time.

Findings include:

Facility policy "Use of Restraint/Seclusion" included: "I. Policy: Carondelet Health Network's philosophy is the patient has the right to be free from restraints and/or seclusion of any form that are not medically necessary, or are used as a means of coercion, discipline, convenience, or retaliation by staff.
Restraint and /or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff, others and must be discontinued at the earliest possible time. Restraint and /or seclusion can only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm...
V. Procedure for Use of Restraints for Non-Violent, Non-Self Destructive patients: ...Patient Re-Assessment, Monitoring and Provision of Care: The condition of the patient is assessed monitored and re-evaluated. An assigned staff member who is trained and competent accomplished monitoring through regular in-person observation. The condition of the patient must be monitored every 2 hours...The patient's psychological status and readiness for discontinuation of restraint are assessed...Discontinuation of Restraint: Restraint use is ended at the earliest possible time based on the assessment and reevaluation of the patient's condition. Restraint use is discontinued when the patient meets the behavior criteria for their discontinuation or alternatives to restraint are effective...
VI. Documentation: Staff Education: Staff must be trained and be able to demonstrate competency in the application of restraints, monitoring, assessing, and providing care for a patient before performing restraint as part of their orientation and on a periodic basis. Staff orientation and education will support a culture emphasizing prevention and appropriate use of restraints. During this training, alternatives to restraints will be explored and encouraged. All staff having direct patient contact and involved in the care of patient's with restraints will have ongoing education and training in the proper and safe use of restraints. Training based on specific patient population needs and the role of the health care provider in managing patients in restraints may include: ...Interventions to help patients meet behavioral criteria for discontinuation of restraint; Identification of behavioral changes that indicate restraining is no longer necessary;...Recognizing readiness for discontinuing restraint."

Review of the medical record for patient #17 revealed the patient had been admitted to the facility on 10/11/12, positive for alcohol (ETOH) use, garbled speech, hyponatremia, and malnutrition. The report from the Tucson Fire department included: A friend had called 911 due to the patient "not making sense and drinking the past few days." The ETOH withdrawal was resolved on 10/18/12. Patient #17 was on Clinical Institute Withdrawal Assessment (CIWA) protocol until 10/24/12. The restraints were ordered on 10/31/12 and 11/01/12, at 0800 hours: "Patient has a tracheal/endotracheal tube, invasive catheter, lines (circled), or tubes necessary to maintain nutrition or medication, and is unable to follow verbal instruction and/or understand the risk, benefits, and alternative treatments for which the tube/line has been placed. The patient exhibits lack of decision making ability and is confused, delirious, agitated or combative and is grabbing and pulling at the tube/lines in an attempt to dislodge them OR patient is deemed unsafe to ambulate related to physical causes such as back or extremity injuries, vertigo, etc., but persists in attempting to ambulate."

The physician restraint orders non-violent/non-self destructive form included: Section 5: "This patient will be released from restraint when the following criteria have been met. Cognitive Status improved and no longer confused. No longer attempting to grab/dislodge tubes or lines. Patient safe to ambulate." The restraint flow sheet revealed the alternatives attempted were #2. Distractions/Diversions.

10/23/12, the physician ordered placement of a Peripherally Inserted Central Catheter (PICC)and insertion of a Naso-Gastric (NG) tube for 30 cubic centimeters/hour (cc/hr) of Jevity (tube feeding). Patient #17 was punching and kicking when the staff tried to insert the NG tube. No documentation was found the patient ever had the NG tube inserted. A Gastro-Intestinal (GI) consult was ordered on 10/31/12, for placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube.

The surveyor observed Patient #17 during an interview conducted on 10/31/12, at 1530 hours, accompanied by the Manager of the Telemetry Unit. Patient #17 was sitting up in bed with wrist restraints applied and an activity apron across her lap that she was unable to reach. A sitter was in the chair next to the patient's bedside. The patient was sitting quietly, not observed pulling or picking at her Intravenous (IV) site. She responded happily to conversation but was confused.

The Manager of the Telemetry Unit acknowledged Patient #17 did not need to continue with restraints while a sitter was assigned to the patient.

The surveyor, accompanied by the Director of Behavioral Health Services, observed Patient #17 sleeping in upper extremity (wrist) restraints, on 11/01/12 at 0850 hours. A sitter was at the bedside. The patient's bed alarm was noted on the bedside table.

The Director of Behavioral Health verified the patient should not continue both in restraints and have a sitter. The sitter acknowledged the patient was sleeping and resting quietly since the sitter arrived at 0700 hours. The nursing progress notes on 11/01/12, at 0130 hours included: "Pt is awake and sitting in bed. Patient refuses water to drink. No further nursing note was found for 11/01/12. The Director of the Telemetry Unit acknowledged the nurses chart by exception.

The Registered Nurse (RN) assigned to Patient #17, revealed in an interview conducted on 11/01/12, the patient had been increasingly active and angry yesterday. Patient #17 assaulted the Respiratory Therapist while he was attempting to draw an arterial blood gas. The RN revealed the patient was very unpredictable and not taking fluids or medications. She was unable to find a sitter for the patient when the restraint order was initiated. She verified she has seen the use of restraints and sitters at the same time on the Unit.

Review of the nursing progress notes revealed Patient #17 had been in restraints with a sitter soon after they were initiated on 10/31/12 at 0800. The RN acknowledged a sitter was present until the restraints were discontinued on 11/01/12, after the RN morning assessment at 0900 hours. She verified a sitter had not been assigned to the patient prior to the use of restraints.

The facility Job Description: Companion/Sitter included: "Position Summary: Provides continual bedside non-skilled observation to assigned patient. Ensures patient safety. Position Duties: 1.1 Remains at patient bedside at all times...1.4 Promptly refer to supervising RN any signs or symptom that may indicate a change in condition. 1.5 Assist in calming or reorienting patient in cases of agitation or confusion..."

Review of the personnel files for the RN and the Manager of the Telemetry Unit revealed neither had inservices on restraint training within the past 2 years.

Based on review of hospital documents, medical records, hospital policies and procedures and staff interviews, it was determined for two patients who had unexpected/unplanned occurrences and outcomes during their hospitalization (Patients #1 and #4):

A-0286: the hospital failed to identify, analyze the causes and implement preventive actions in order to prevent recurrences.

The effect of the systemic probelm resulted in the hospital's ability to ensure the provision of quality health care in a safe environment.

Based on reviews of clinical records, hospital policies and procedures and hospital reports and staff interviews, it was determined for two patients who had unexpected/unplanned occurrences and outcomes during their hospitalization (Patients #1, and #4), the hospital failed to identify, analyze the causes and implement preventive actions in order to prevent recurrences.

Findings include:

The hospital's policy titled Occurrence Reporting included: "The occurrence reporting process supports the organizational approach to patient safety and performance improvement and provides the organization the following: a. Data related to the nature and frequency of unusual occurrences, so that additional review, analysis, and steps to improve key process may be taken to prevent recurrence...DEFINITIONS...Occurrence: any event or circumstance that is not in keeping with the routine, normal operations of the hospital, its associates, or in routine patient care. Examples include but are not limited to, medication errors, adverse drug events, falls, errors involving treatment or procedures, a situation which resulted in a loss or damage to property, or personal injury...Adverse event: An untoward, undesirable, and usually unanticipated event, such as death of a patient..ROLES AND RESPONSIBILITIES...Associates are required to report any incident promptly and completely. Failure to report or an attempt to cover up an incident will be reviewed and may be grounds for disciplinary action including dismissal...Each director or manager will ensure the associates and supervisors have been instructed in the completion of the Occurrence Report. In addition, each director or manager completes and validate follow-up, with closure within 5 business days of the reported event...The Quality Management Department will be responsible for oversight of the occurrence reporting process, including stratification of events based on predetermined criteria, reporting of trends, identification of adverse events, and initiation of intense analyses as indicated...The Occurrence Report will originate with the person(s) directly involved or having firsthand knowledge of an unusual incident...The Occurrence Report will be completed immediately after the event or as soon as the incident is found to have taken place. The Report will be clear, and include all pertinent, factual and objective information...Upon receipt, the area manager or director will review the report. The manager/director will review the report for completeness, verify facts, and review additional documentation. The Manager/Director will complete and validate follow-up actions and close the event within 5 business days of the event report."

Patient #1 was admitted to the hospital on 3/14/2012. The physician's Emergency Department documentation revealed the patient was found slumped over in her car and brought in by ambulance. The patient was lethargic, difficult to arouse and was admitted and diagnosed with toxic metabolic encephalopathy

Nursing documentation dated 3/17/2012 at 10:30 a.m. included: "Assessment complete. No c/o (complaint of) pain at this time. Call light within reach. Side rails up x 2." Although the RN's documentation infers the patient was in bed with 2 side rails up at the time of the assessment, there was documentation on the Patient Care Interventions form dated 3/17/2012 that the patient was in a chair at 9 a.m. and received a bath and linen change. Check marks on the form revealed the patient was up in the chair from 9 a.m. until 2 p.m. and that there was family visiting from 8 a.m. to 11 a.m.

The next documentation by the patient's RN was at "~1400" (approximately 2 p.m.) and included: "Pt found by either RT (Respiratory Therapist) or PCT (Patient Care Technician), choking on lunch. Attempted Heimlich, but not successful (secondary) size of pt. Code Blue called, Dr. (name of physician) (attending) came to code. Code team did remove food from airway. Pt intubated & bagged while CPR performed...Pt successfully revived & transferred to Neuro ICU...."

Documentation in the Code Blue Charting Flowsheet dated 3/17/2012 revealed the time of arrest was "1346" (1:46 p.m.). The patient had no pulse or respirations from 1:46 p.m. until 1:59 p.m. at which time a blood pressure and pulse were obtained.

Physician documentation dated 3/14/2012 included: "...She has had frequent admissions to the St. Jos's ER...She has history of cryptogenic hepatic cirrhosis ...with frequent episodes of hepatic encephalopathy...She was most recently admitted on 03/01/2012 with hepatic encephalopathy, high ammonia, UTI which was treated...She is edentulous and has dentures which are not in now. She has been pretty much sleeping all day except for brief periods when she can be awakened and can converse. She has toxic metabolic encephalopathy, most likely hepatic even with the low ammonia. She has a UTI now which may have been a trigger...."

Physician documentation dated 3/17/2012 related to the patient's Code Arrest included: "...While eating lunch, unfortunately, she choked on her meat and collapsed. That was witnessed by the respiratory therapist, who tried the Heimlich maneuver with no success. The patient, when (sic) collapsed, a code was called. On our arrival, patient was pulseless (PEA, CPR ACLS protocol started). The patient was intubated by Dr. (name), who cleared her airway of 2 large meat segments. The patient was intubated. CPR was started, not interrupted even during the intubation. As the code started, the patient was found to have no IV access being prepared for discharge...Currently, patient status post code with normal vitals and patient is on a ventilator."

Another physician who responded to the Code Arrest and performed the oral endotracheal intubation on the patient, documented: "Procedure was performed as part of the resuscitation effort after a code blue was called when the patient abruptly developed respiratory distress while eating and then went into a cardiopulmonary arrest. Aspiration was suspected but Heimlich maneuver by the respiratory therapist prior to the code team arrival was unsuccessful. The patient was initially ventilated by a bag mask...CPR was initiated with ACLS protocol in progress. Direct laryngoscopy was performed ...A significant amount of thick whitish food material was visualized in the posterior pharynx and supraglottic area and this was suctioned clear with a little difficulty...."

The Respiratory Therapy section of the clinical record was reviewed for documentation by the RT who found and responded to the patient choking. The only documentation located was dated 03/17/2012 at "1345" (1:45 p.m.): "Code Arrest Complex." There was no other documentation by the RT that documented the events surrounding the patient choking. The Director of Respiratory Therapy and Nurse and the current Director of the Nursing Unit reported during later interviews that the RT's documentation of the event was incomplete and did not reflect the actual events and actions taken.

Further documentation in the clinical record revealed the patient remained on life support in the ICU until 3/19/2012 when she died. Physician documentation in the Discharge Summary included: "She was admitted to the neuro ICU on 03/17/2012 after she choked on her meal. She subsequently went into respiratory arrest and then pulseless electrical activity arrest. She was coded for about 15 minutes...She arrived to neuro ICU, intubated and hemodynamically unstable. Overnight, she developed myoclonic jerks likely secondary to anoxic brain injury. A head CT did not reveal any changes...EEG later evolved to electrocerebral silence...The family were duly informed and husband felt he did not want patient to live like this if she will have even more deficits. It was decided at this time to wean off all therapy and terminally extubate patient. Cause of death: Anoxic brain injury secondary to pulseless electrical activity secondary to respiratory arrest. Secondary cause is toxic metabolic encephalopathy. Time of death 11:22 hours on 03/19/2012."

The surveyor requested hospital administration to provide documentation of the hospital's comprehensive investigation/analysis of the incident. Two reports related to the incident were given to the surveyor. One report was written by the RN assigned to the care of the patient when the incident occurred and the second report was written by the RT who found the patient. The date the incident was reported by the RN was "04/03/2012" and the date the incident was reported by the RT was "04/04/2012" , 17 and 18 days respectively after the incident.

The RN's report included: "...Upon entering the room, a respiratory therapist was attempting to perform the Heimlich maneuver on the patient. She told us the patient was choking on a piece of chicken. The patient was in a chair at the time, but because of her size, we were not able to get our arms around her. She was also slipping out of the chair, on the floor. We were attempting to place the patient in a position that would allow us to perform the Heimlich. The RT yelled that she needed suction. I ran and got a suction setup, calling a code blue at the same time. Upon re-entering the patient room, other help arrived and placed the patient in her bed and started to perform CPR...."

The Chief Nursing Officer documented in the report on 4/5/2012 at 6:53 p.m.: "Under review for quality." The Manager of the unit documented on 4/18/2012 at 12:43 p.m., over 30 days after the incident: "Reviewed with PCT, RT, RN. Patient in chair with call bell when RT found pt choking and attempted Heimlick (sic) while calling for help. All associates responded, code arrest called. Patient transferred to a higher level of care." The report was "closed" by the manager on 4/18/2012.

The RT's report of the incident dated 4/4/2012 included: "I walked into pt room planning on giving a breathing tx (treatment), and found the pt choaking (sic) on food. Pt was still moving air so instructed pt to cough it up. The PCT came in and I asked her to get help. The Pt gasped and lodged the food further into her airway. The pt had yellow socks on, and I alone could not stand the patient up. I tried the Heimlich maneuver which failed. RN and PCT came back code was called, and proceeded to help stand the patient up to Heimlich again. Pt passed out and coded. With the help of the ER RT, RN, PCT and I got pt into bed and started CPR. Dr. (name) suctioned a large chunk of partially chewed chicken out of her airway prior to intubation with the suction tubing (not suction catheter). After intubation pt was transferred to Neuro ICU."

Documentation in the "Follow Up Comments" section of the form revealed the report was "Reviewed with PCT and RN assigned to patient" by the Nurse Manager on 4/18/2012 and reviewed by the CNO on 4/19/2012, over 30 days after the incident.

The surveyor asked hospital administration if there was any other documentation to support that a comprehensive analysis of the incident occurred. The surveyor was referred to the hospital's Risk Manager, and an interview was conducted with her on 10/17/2012. The Risk Manager provided the surveyor with a folder of her handwritten notes and internal e-mails related to the incident which she reviewed with the surveyor during the interview. According to her notes, the patient's family member contacted the nursing unit's Clinical Nurse Leader (CNL) on 4/2/2012 with concerns and questions surrounding the circumstances that lead to the patient's death. The notes revealed the Patient Advocate and the Risk Manager were then informed. The Risk Manager's notes revealed she requested the nursing unit's Nurse Manager to document the event into the hospital's electronic reporting system on 4/2/2012. The Risk Manager reported the Nurse Manager and CNL's on the unit were responsible for conducting an analysis/investigation of unexpected events and correcting any identified areas of concern. The Risk Manager then referred the surveyor to the Patient Advocate to discuss the hospitals policies and procedures for handling patient/patient representative concerns. The Manager of the Patient Advocate department reported she was not aware of the incident but would follow up with the Patient Advocate who was involved in any contact with the family. The surveyor was then provided with two pages of handwritten notes from the Patient Advocate who had contact with the family member and the Risk Manager.

The Senior Nursing Director and the Director of the Telemetry Unit reported the incident was originally investigated by the Manager of the Unit at that time who was no longer employed by the hospital and they could not locate any additional documentation to support that. They reported they were not directly involved in the investigation and were not aware of any concerns.

An interview was conducted on 10/17/2012 with the PCT who was assigned to the patient's care on 3/17/2012. The PCT reported the patient had a "good breakfast" and assisted the patient out of bed into a chair around 10 a.m. At that time the PCT assisted the patient with a bath and changed the bed linens. The PCT recalled the patient remained up in the chair when the lunch trays arrived on the unit which she stated was between 11:30 a.m. and 12 noon. The PCT stated she set up the patient's meal on the tray in front of her and "sliced" the chicken. The PCT stated she did not go back to the patient's room until she heard the RT call for help, a period of between one and one-half to two hours later.

An interview was conducted on 10/17/2012 with the RT who found the patient choking. The RT stated she was administering a breathing treatment to a patient across the hall when a family member told her they thought the patient across the hall was choking and needed help. The RT reported she stopped and listened and could hear the patient coughing. When she entered the room, the patient had her hands around her throat indicating she was choking. The RT stated the patient was still able to move air at that time. Then the patient took a breath and lost her airway. The RT called for help and attempted to perform a Heimlich maneuver but was unsuccessful because of the patient's size. The RT stated that when the code team arrived with the code cart, there was no mask available to administer the oxygen. She stated the patient choked on a large piece of chicken that was difficult even for the physician to remove. She stated the patient was "edentulous" (no teeth and no dentures) and did not know why she was served chicken.

The RT's documented report of the incident did not include all of the details provided to the surveyor during the above interview.

Interviews were conducted on 10/16 and 10/17/2012 with the current Director of the Telemetry Unit and the hospital's Senior Nursing Director. The surveyor questioned why the patient's lunch tray delivered was still in her room at 2 p.m. and if there was a policy and procedure regarding the length of time meal trays would be left in a patient room and they did not know.

The Hospital was not able to provide documented evidence that a coordinated and comprehensive analysis was conducted on the events that surrounded the patient choking on chicken that resulted in her death and no documentation that a plan of correction was developed, implemented, and monitored to prevent a recurrence.

-Patient #4 was taken to the ED by the police department on 9/16/2012 at 11:42 p.m. Documentation in the clinical record revealed the patient was "severely mentally ill" with diagnoses including Bipolar (severe manic history), Depression, and Schizophrenia (explosive personality). The patient reportedly had not been taking his psychiatric medications, was "SI and HI" (suicidal and homicidal ideation), complained of back pain, and had a razor blade with a plan to slice his throat.

A psychological evaluation was conducted by a licensed therapist on 9/17/2012 at 6:47 a.m. whose documentation included the following: "Pt stated that he was in pain and could barely walk. He eventually was helped by a stranger who called 911. The pt was found by TPD with a razor blade that he threatened to kill himself with, so it was taken away from the pt. Upon arrival to the ED, the pt continued to c/o SI and HI. He asked for pain medication and when he was informed that he would not receive narcotics in the ED, the pt escalated and required sedation for the safety of the staff. Shortly after, while unattended for five minutes, the pt took the cord from his window blinds and wrapped it around his neck. Pt then hung his body off of the stretcher bed in an attempt to strangle himself. This writer removed the string from his neck and the pt was moved to another room in the ED where he could be monitored more closely. Pt continued to report that he no longer needed pain medication because he now knew of a way to 'end my pain.' Pt stated that he would say the 'right things' to get out so that he can go home and kill himself...." There was no nursing documentation that referred to the incident.

The physician's Emergency Department Note dated 9/17/2012 at 8:06 a.m. included the following documentation of the incident: "...Around 3:00 a.m., patient suddenly became quite explosive and was yelling obscenities and sitting up and screaming at the staff stating he was going to kill himself immediately if he was not given his high strength oxycodone. He then grabbed a monitor wire when he was temporarily placed in bed 22, and grabbed the wire from the monitor and tried to wrap his neck with the wire. This was immediately witnessed and he was not able to wrap it around his neck. He was removed from bed 22 and he was brought into bed 23 immediately. He had no airway compromise, no abrasion to his neck. No stridor. No shortness of breath...."

A hospital internal report revealed an event that occurred on 9/17/2012 at "0325" (3:25 a.m.) The narrative description of the event included: "Pt presented to the ED c/o SI and HI due to chronic pain issues. Pt was told he would not be given any narcotic pain medication here in this ED by Dr. (name of ED physician) due to the pt presenting to multiple hospitals over the past 48 hours. Pt began escalating in the ED verbally and was given Valium and Ativan. This writer was three doors down from the pt in the hallway while he was being given medication. After administering the pt medication, the RN (name of ED RN assigned to the patient), left the pt alone in his room and turned off the pt lights in his room. Five minutes later, (name of Behavioral Health Technician), and I were speaking int he hallway when a housekeeping associate, (name), informed us that the pt appeared to need help. When (name of BHT) and I arrived to the room, the pt was lying on his left side, toward the top of the stretcher, with the top third of his body off of the bed. Upon closer examination of the pt, due to the lights being off, it was observed that the pt had wrapped the window blinds cord around his neck in an attempt to hurt himself. (Name of BHT) was able to hold the pt up while this writer unwrapped the cord from around his neck. Pt was left with an imprint of the cord on his neck. He then stated, 'Why didn't you just leave me there?'" The Follow Up Comments of the hospital's report was documented by a Nurse Manager on 9/25/2012 at 2:22 p.m. and included: "The pt c/c (chief complaint" was pain which was being addressed. He had been seen in this and other EC then D/C'd (discharged" cleared for out pt treatment." There was no other documentation on the form that addressed the behavioral health patient with suicidal ideation being left unattended in a room with cords on a window blind he used to wrap around his neck.

The surveyor asked hospital administration to provide documented evidence that the event was thoroughly investigated and analyzed including the discrepancy in the behavioral health licensed therapist's documented account of the event and the ED physician's documented account. The surveyor was told there was no additional documentation.

An interview was conducted on 10/31/2012 with the Nurse Manager who investigated the event and documented the Follow Up Comments on 9/25/2012. The Nurse Manager acknowledged he was assigned to investigate the incident and told the surveyor his investigation revealed the patient was not assigned to the care of the RN named in the event. The clinical record was reviewed with the Nurse Manager during the interview, and he acknowledged documentation in the record that the RN named in the incident report was assigned to the patient and he was not able to recall why he thought differently. He said the report that the patient wrapped the cord of window blinds around his neck was not accurate because there were no window blinds with a cord in Room 22 where the patient was. The Nurse Manager was asked if he interviewed the writer of the event report and he said he did not and in fact thought that person was a Behavioral Health Technician and did not realize until this interview that the writer was the Psychiatric Assessment Team's Licensed Therapist. He added that he thought the report was a BHT's "perception" of the event and took the physician's account of the incident as what actually happened.

A telephone interview was conducted shortly thereafter with the Psychiatric Assessment Team's Licensed Therapist. She recalled the patient and was able to repeat the sequence of events she documented. She was asked to clarify if the patient used cords to a monitor in the room or cords of a window blind. She stated that she was present in the room and the patient used the cord to the window blinds and not monitor cords. She added that she removed the cord and the imprint of the cord was left on his neck.

A member of the hospital's nursing administration went to the ED after the above interviews on 10/31/2012 and reported to the surveyor that Room 22 does have window blinds with a cord.

The hospital was not able to provide documented evidence that a comprehensive investigation and analysis was conducted of suicidal patient left unattended in a room where he had access to a cord which he used to wrap around his neck. There was no documentation that addressed the discrepancies of the therapist's documentation with the physician's documentation and that there was no documentation of the event by the nursing staff whatsoever.

Based on review of hospital documents, medical records, hospital policies and procedures and interviews, it was determined:

A-0395:

-For Patient #2, the hospital failed to ensure the patient's care was supervised by Registered Nurse following hospital policies and procedures for: 1) Observing the status of in-patient behavioral health patients at least every 15 minutes and 2) Responding to the patient when she was found unresponsive.

-For Patient #4, the hospital failed to ensure the RN supervised the suicidal patient's care in a safe environment in the Emergency Department.

The effect of the problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record reviews, reviews of policies and procedures and hospital reports and records and staff interviews, it was determined for two patients, (Patients #2 and #4), the hospital failed to ensure the patients care was supervised by a Registered Nurse (RN) following hospital policies and procedures for: 1) Observing the status of in-patient behavioral health patients at least every 15 minutes and responding to a patient found unresponsive (Patient #2); and 2) Supervising and ensuring the safety of a suicidal patient in the Emergency Department (Patient #4).

Findings include:

1. The hospital's policy and procedure titled, Precautions on Behavioral Health Units, included the following: "Behavioral Health staff will follow precautions to prevent self-destructive behavior of patients on the behavioral health units...Purpose...To create guidelines to direct staff in protecting patients who may have suicidal, homicidal ideation from action on their destructive impulses or are a danger to injury because of an inability to care for self. Three levels of observation will be used based on the patient's ability to contract for safety and no self-harm...Definitions...Q (every) 15 minute Check Status: Behavioral health staff will document the patient's whereabouts every 15 minutes, and mood and affect at least once an hour. Any significant change in mood, affect, or behavior will immediately be reported to the RN."

The hospital's policy and procedure titled, Special Observation flow sheet on Behavioral Health Units, included the following: "Carondelet Behavioral Health is committed to the welfare and safety of patients. Direct observation of the patient is the best method to ensure that client needs are being met and that clients are safe...The special observation flow sheet, also known as the 'Q15 minute check sheet' for the ECU, is used to record the location of all inpatients within Carondelet Behavioral Health and may include information about behavior, and mental status observations if applicable."

2. The hospital's policy and procedure titled, "Medical Emergencies; Behavioral Health" included the following: "The purpose of treatment of medical emergencies is to assure quality patient care and an appropriate immediate response by hospital personnel...V. Special Considerations...1. Any staff who observe or become aware of a condition requiring immediate medical evaluation will assess the situation, initiate CPR if warranted, call for help and notify the RN. 2. The responding RN will immediately evaluate the situation. 3. If warranted, the nurse will administer immediate emergency care, such as CPR or First Aid. 4. The nurse will notify the attending psychiatrist as soon as possible following the emergency...VI. Preferred Process CSJ O'Rielly Care Center...1. In a life-threatening or code arrest situation for inpatients housed on the second floor of CSJ O'Rielly Care Center, immediately call external medical emergency (9-911) personnel as well as the CSJ operator "0" ask for STAT ACAT (Advanced Clinical Assessment Team)...Code Arrest Situations...ACAT Team: Will assist unit staff in providing emergency care to the patient. EMS Responders: Will provide emergency care and transport to an Emergency Department...House Supervisor: Will coordinate and direct care activities during the arrest situation to ensure patient safety measures are followed."

The hospital's policy and procedure titled, Rapid Response Team (RRT) included: "...III. Definitions...a team of specially trained health care personnel that responds to calls from patient care areas, for assistance with an actual or perceived decline in a patient's condition. The goal of the team is to bring critical care expertise to the patient when needed, to facilitate the timely transfer of patients to a higher level of care, to provide early and rapid intervention in order to reduce the occurrence of respiratory or cardiac arrest, and ultimately to minimize adverse or unanticipated patient outcomes...IV. Roles and Responsibilities...Rapid Response Team RN(s)-Conducts assessments of the patient and the situation...Initiates rescue interventions per approved protocols...Communicates with the primary care physician regarding the patient's condition and needs...Consults with critical care or emergency physicians as needed...Clinical Supervisor...Manages the environment...Facilitates communication with the family, among the team, and with physicians...Respiratory Therapist-Provides respiratory assessment, airway support and management...Documentation...RRT nurse documents assessment findings, interventions, calls to physicians, and patient outcomes on the RRT documentation form. All sections of the RRT documentation form must be completed. A copy of the completed form will be forwarded to the quality office."

There was also a hospital policy and procedure titled Code Arrest/Code Blue Management within CHN Facilities and included: "CHN associates that are CPR trained are expected to initiate basic life support measures for patients until the code team arrives. Unless otherwise ordered, Cardiopulmonary resuscitation (CPR) will be initiated on all patients that experience a cardiac and/or respiratory arrest...Definitions...Code Arrest - Sudden Collapse with cessation of heartbeat and/or respirations...Code Team - a designated team of associates that are specifically trained to respond to code arrest situations at CHN facilities...Code Team Members 1. RN caring for the patient 2. ICU and/or Telemetry RN 3. Resource Nurse/Rapid Response Nurse (if available) 4. Emergency Center Physician/First responding Physician 5. Pharmacist 6. Respiratory Therapists (2) 7. Clinical Supervisor / Patient Flow Coordinator...Process 1. Call for help & stay with the patient...To Activate the Code Team Dial '911" to connect with the hospital operator...2. Begin CPR...3. Attached the AED if available...4. Once the Code Team Arrives: Stay with the patient and assist with the code within your scope of practice...5. After the code...:"


Patient #2 was admitted to the Hospital's behavioral health unit, O'Reilly Care Center, on 10/20/2012 after overdosing on metoprolol (antihypertensive), Ativan (benzodiazepine) and diazepam (benzodiazepine). The physician's Behavioral Health Admission Orders dated 10/20/2012 included "Check every 15 minutes."

Nursing Notes dated 10/24/2012 at 2:45 a.m. included the following: "While Techs were making safety checks Pt was discovered lying on the floor in the bathroom unresponsive. Prior to this Pt was seen sitting on the side of her bed at 0100 AM safety check in no acute distress. Last set of vitals were taken at 2400 (secondary) to Pt stating she felt 'a little dizzy when I close my eyes.' Vitals: BP 143/57 P. 88 reg, R. 16. Appeared in no acute distress, A&O x's 3. From 0100 to 0145 Pt was resting quietly in bed during safety rounds. At 0200 Pt up in bathroom as reported by BHT (Behavioral Health Technician) (name of Staff #3). At 0215 BHT (initials of Staff #4) returned from safety rounds and said Pt was up in bathroom still. I instructed the techs to go check on the Pt and it was during this check that Pt was found lying on the floor. Rapid response was immediately called as Pt was assessed to not be breathing and (without) a pulse. House Supervisor called at 0217 and informed of Pt's status. House Supervisor (Staff #1) on unit at 0220. Security and Rapid Response present. Incident occurred between 0200 and 0215. Dr. (name) notified by (name of Staff #1, House Supervisor) at 0230." The documentation was signed by the RN on duty at the time of the incident, Staff #2.

Staff #4 (BHT) documented on 10/24/2012 at 3:50 a.m.: "At 0215 safety rounds pt was in Bathroom upon returning to nsg station reported she was in BR Co worker (initials of Staff #3) stated she was in there at 0200 rounds - returned to pt room to recheck and found pt on floor, unresponsive - not breathing - RN notified."

Staff #3 (BHT) documented on 10/24/1012 at 4:05 a.m.: "At 0200 safety rounds, pt was in bathroom. Pt could be heard breathing. At 0215 rounds, co worker (initials of Staff #4) reported pt was in bathroom. Returned to pt room and found pt on floor of bathroom unresponsive. RN notified."

Documentation in the Behavioral Health Observation Checklist dated 10/24/2012 included Staff #4's initials at 1:45 a.m. with a check-mark in the location column of "Pt Room" and the handwritten comment, "resting quietly." Staff #3's initials were documented at 2 a.m. with a check mark in the location column of "Bathroom/Shower" and the handwritten comment, "In bathroom." Staff #4's initials were documented at 2:15 a.m. along with a check mark in the location column of "Bathroom/Shower" and the handwritten comment, "In bathroom - checked pt on floor RN notified." According to this documentation, the patient was visualized at 1:45 a.m. and not again until she was found dead in the bathroom at 2:15 a.m., a period of 30 minutes.

The physician's Discharge Documentation dictated on 10/24/2012 at 7:22 a.m. included: "Later in the evening, the patient reported to staff feeling slightly dizzy. Vital sings (sic) were normal. She was having difficulty with sleeping, clearly describing eagerness and anxiety about the pending discharge. She was checked on by evening staff in the early morning hours. She was noted to have been in the bathroom with the door closed for about 10 minutes or so. When staff checked on her, they found her completely unresponsive. She appeared to have died in the toilet. There was no evidence of a recent bowel movement or signs consistent with diarrhea. She was taken to the emergency room and our staff met family there to break the news. I was called at approximately 0230 this morning. I reviewed the details of the case, talked with the staff and plan on speaking with the patient's mother later this morning."

There was no documentation by the RRT that detailed the time they were called, who responded, and what their actions were. There was no documentation that a physician in the hospital was called and requested to respond and assist at the time the patient was found unresponsive. The surveyor requested a copy of the Rapid Response Team documentation and was told by hospital administration that the documentation was not able to be located.

An interview was conducted on 10/31/2012 with Staff #1, Director of Network Behavioral Health. Staff #1, an RN, stated she was covering as "House Supervisor" on 10/24/2012 when she received the call for the Rapid Response Team to respond to O'Reilly Care Center at approximately 2:20 a.m. She reported that she immediately responded and was told by Staff #2, the RN Charge Nurse on the unit who was at the nurses station, that the patient "was gone," meaning the patient was dead. Staff #1 reported the Rapid Response Team was present. She acknowledged the Code Team should have been called rather than the Rapid Response Team and that no one on the Rapid Response Team initiated CPR or called the Code Team. She explained that an ED physician responds to Code Blues but not RRT calls. She reported a call was made at the time of the incident to the ED requesting a physician, however, a physician did not respond. Staff #1 reported she called the patient's psychiatrist at approximately 2:30 a.m. who provided orders for two RN's to pronounce death. She said she completed the RRT paperwork and acknowledged the documentation was not able to be located. On 11/1/2012, Staff #1 provided the surveyor with a copy of a "Late Entry" narrative dated 10/31/2012 at 0730 which included: "Documentation for Rapid Response Call on 10/24/12 @ 0215."

Staff #2 was the Registered Nurse on duty on the night of the patient's death. She reported during an interview on 11/1/2012 that the evening was uneventful for the patient except for an episode of the patient reporting she fell dizzy around midnight. The patient's vital signs were normal, and the patient told staff she was nervous about her pending discharge. Staff #2 stated Staff #3 and Staff #4 were taking turns doing the every fifteen minute observation checks. Staff #4 completed the 2:15 a.m. checks and reported to Staff #2 that everyone was in bed except Patient #2. Staff #3 then told her that the patient was in the bathroom at 2 a.m. when she did the checks and both BHT's were directed to check on the patient immediately. The BHT's found the patient in the bathroom on the floor and they activated the bathroom call light. When she arrived, she observed the patient on the floor on her right side in front of the toilet. The patient's extremities were dusky and purple and although she was warm to touch, there were no respirations, pulse, or blood pressure. Staff #2 reported she called the Rapid Response Team. Staff #1, the Network Director of Behavioral Health arrived shortly after the call and assessed the patient. No resuscitative measures were initiated and there was no physician present at any time. The patient's body was transported to a room in the Emergency Department for viewing by a family member.

Staff #3, a BHT, acknowledged during an interview on 11/1/2012 at 8:45 a.m. that she made the every fifteen minute checks on the patients at 2 a.m. and Patient #2 was in her room in the bathroom at that time. She reported the door was closed and she wanted to respect the patient's privacy so did not open the door but could hear the patient breathing. Staff #3 said the 2:15 a.m. rounds were made by Staff #4. At the end of those rounds, Staff #4 came back to the nurses station and told her all of the patients were in their rooms except for Patient #2 who was in the bathroom. Staff #3 said that because the patient was in the bathroom at 2 a.m., they both went back to the patient's room, opened the bathroom door, and found the patient lying on the floor on her right side and unresponsive in front of the toilet. They pulled the call light in the bathroom which alerted the RN in the nurses station and the RN arrived shortly thereafter. Staff #3 reported CPR was not initiated.

Staff #4, a BHT, reported in an interview on 11/1/2012 that she made the patient observation checks at 1:45 a.m. at which time Patient #2 was in laying in bed. Staff #3 performed the observation checks at 2 a.m. and Staff #4 did not know Patient #2 was in the bathroom during that observation check. Staff #4 made the 2:15 a.m. and noted the patient was in the bathroom but did not directly visualize her. When Staff #4 reported to the RN after the observation checks that Patient #2 was in the bathroom, Staff #3 reported the patient was in the bathroom at 2 a.m. so both Staff #3 and Staff #4 went to the patient's room to check on her. At that time the patient was found unresponsive on the floor in front of the toilet. Staff #4 reported the patient was warm to touch, however, her extremities were purple/blue. Staff #4 stated the call light in the bathroom was activated, and the RN responded right away. Staff #4 reported CPR was not initiated.

Separate interviews were conducted with the two Respiratory Therapists (Staff #5 and Staff #6) who were on the RRT at the time of the event. They acknowledged receiving and responding to the call, however, when they arrived, they were directed to leave. Staff #5 stated he was not told why and was informed just 24 hours prior to this interview that the patient died on the unit. Staff #6 stated he was told by the Critical Care Unit (CCU) RN who was on the RRT that the patient was dead. Both Staff #5 and #6 reported they never observed or assessed the patient and were not a part of the decision making regarding resuscitative efforts.

The surveyor requested an interview with the CCU RN who was on the Rapid Response Team, however, hospital administration reported she did not respond to their messages.

In summary, Patient #2 was an inpatient on the behavioral health unit. Observation checks were to be made every fifteen minutes per physician orders. The patient was observed by Staff #4 (BHT) resting quietly in her room at 1:45 a.m. on 10/24/2012. The next check check was by Staff #3 (BHT) at 2 a.m. who did not directly observe the patient but documented the patient was in the bathroom and later reported the bathroom door was closed but she could hear breathing. During the 2:15 a.m. check Staff #4 did not directly observe the patient and reported to the Charge RN that the patient was in the bathroom. The Charge RN sent both BHT's back to the patient's room where she was was found in the bathroom on the floor. The BHT's alerted the Charge RN who assessed the patient to have no pulse, respirations or blood pressure and purple discoloration of her extremities. CPR was not initiated. The RN returned to the nurses station and called for the Rapid Response Team rather than the Code Team. There was conflicting information whether or not a physician in the ED was called and why that physician did not respond. There was no documentation of the RRT activities on the designated RRT documentation form that included who responded, what care was provided, and the patient outcome.

3. The hospital's policy and procedure titled Patient Assessment and Plan of Care included: "Re-Assessment Patients are re-assessed each time a different RN is assigned to the patient, when there is a change in the patient's condition, and in accordance with specifid department guidelines...Document the assessment data related to the patient's physical, psychological, social and spiritual status in the patient medical record on admission, and on an ongoing basis as appropriate...Documentation in the patient's record should reflect the patient assessments, interventions, response to interventions, consultations, and plan for care."

Patient #4 was taken to the ED on 9/16/2012 with suicidal ideation. (Refer to Tag A-0263 for specific details related to Patient #4). The patient was left unattended in a room with window blinds with a cord used to raise and lower the blinds. While alone, the patient wrapped the cord around his neck and was observed by a housekeeper who alerted staff. There was no documentation of the incident by an RN or documentation that the patient was assessed immediately after the incident.

The patient's record was reviewed with the Nurse Manager who investigated the incident and he acknowledged there was no nursing documentation of the incident or nursing assessment immediately after the incident and was not aware of it prior to this interview.