HospitalInspections.org

Based on policy reviews, medical record review, video footage review, job description review, and staff and provider interviews, the governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights for a safe environment; an organized nursing service for supervision of nursing care; and an effective emergency services to meet behavioral health patient care needs.

The findings include:

1. Hospital staff failed to ensure a safe environment for an Emergency Department (ED) behavioral health patient by not monitoring the patient for signs of life for 1 of 1 sampled patients that expired in a locked behavioral health area of the Emergency Department (Patient#21).

~ Cross refer to §482.13 Patient Rights' Standard: Tag 0144

2. Hospital staff failed to secure 1 of 1 EVS (Environmental Services) carts which contained hazardous items and chemical solution in a locked behavioral health area of the Emergency Department.

~ Cross refer to §482.13 Patient Rights' Standard: Tag 0144

3. The hospital failed to ensure nursing staff was available to supervise, assess, and monitor a behavioral health patient in a locked behavioral health area of the Emergency Department (ED) for 1 of 1 sampled behavioral health patients that expired in the ED (Patient#21).

~ Cross refer to §482.23 Nursing Services Standard: Tag A0395

4. Emergency Department (ED) staff failed to evaluate patient care by failing to monitor, reassess and address a patient's change in condition and subsequent death for 1 of 1 sampled behavioral health patients that expired in the ED (Patient#21).

~ Cross refer to §482.55 Emergency Services Standard: Tag 1104

Based on policy and procedure reviews, medical record review, video footage reviews and staff interviews, the hospital staff failed to promote and protect patient's rights by failing to provide a safe environment for behavioral health patients in a locked area of the Emergency Department.

The findings include:

1. The hospital staff failed to ensure a safe environment for an Emergency Department (ED) behavioral health patient by not monitoring the patient for signs of life for 1 of 1 sampled patients that expired in a locked behavioral health area of the Emergency Department (Patient#21)

~ Cross refer to 482.13 Patient Rights Care in a Safe Setting Standard: Tag 0144

2. Hospital staff failed to secure 1 of 1 EVS (Environmental Services) carts which contained hazardous items and chemical solution in a locked behavioral health area of the Emergency Department.

~ Cross refer to 482.13 Patient Rights Care in a Safe Setting Standard: Tag 0144

Based on policy and procedure reviews, medical record review, video footage reviews, and staff and provider interviews, the hospital staff failed to ensure a safe environment for an Emergency Department (ED) behavioral health patient by not monitoring the patient for signs of life for 1 of 1 sampled patients that expired in a locked behavioral health area of the Emergency Department (Patient#21); hospital staff failed to secure 1 of 1 EVS (Environmental Services) carts which contained hazardous items and chemical solution in a locked behavioral health area of the Emergency Department.

The findings include:

1. Review on 08/23/2024 of the hospital policy "Suicide Risk and Assessment Precautions," effective 05/2023, revealed, "... In the secure behavioral health units ... close observation every 15 min (fifteen minutes) ... Definitions: ... "Close observation" regular and ongoing observation with a minimum of every 15-minute checks."

Medical record review revealed Patient#21 (Pt#21), a 30-year-old male, who presented to the emergency department (ED) by ambulance (EMS-Emergency Medical Services) on 02/15/2024 at 2151 with complaints of hallucinations and suicidal ideations. Review of the ED Provider Note, on 02/15/2024 at 2222, revealed Pt#21 reported suicidal ideation for one (1) year with a plan to take all his medications at once. Physician Orders were placed on 02/15/2024 at 2313 for "ED Behavioral Health Holding" (to keep the patient in the ED until a psychiatric evaluation occurs) and to obtain vital signs every shift. At 2314, a Physician Order was placed for observation every 15 minutes. Review of the Rapid Initial Screening on 02/16/2024 at 0028 revealed the following vital signs: blood pressure 124/77, heart rate 101, respirations 18, and an oxygen of 100%. Review of the nursing assessment at 0033 revealed, "No Respiratory Distress ... Cardiovascular: Regular Rate, Pulses Strong ..." Review of the Observation Record revealed Pt#21 arrived in the CSU (Crisis Stabilization Unit - locked unit attached to the Emergency Department) at 0121 (video review showed 0122). The CSU observation record revealed documentation of every 15 minute patient observations, beginning on 02/16/2024 at 0130 until 0845. Review of the Nursing Assistant (NA) Note on 02/16/2024 at 0853 revealed, "I writer went to patient room to give him breakfast (sic) tray. Patient was laying on his stomach with face in the pillow. I called his name several times and no answer. I shook patient and no response. I put my hand on patient (sic) back and felt no rise. I turned light on and did not see patient back rise. I motioned to psych (psychiatric) provider to come to the room and called medic (paramedic) to come to the room. Psych provider came in the room and saw patient did not have a pulse ..." Review of the Registered Nurse (RN) Note at 0900 revealed, "called code blue to CSU, pt found to be not breathing, pulseless, no sign of life, pt was facedown (sic) in prone position, already had pooling of blood, it appears pt had been this way for some time, early signs of rigor (stiffening of the joints and muscles) and stiffness, monitor shows asystole, MD (doctor) pronounced pt deceased." Review of the ED Provider Note at 0906 revealed, "... Pt was laying (sic) face down on bed with face buried in pillow. I turned him on his side, no breathing noted, pulseless. Cool to touch, noted with lividity (bluish-purple discoloration of the skin that occurs after death). No heart sounds ... I told staff I did not feel we needed to start CPR (cardiopulmonary resuscitation), we confirmed asystole (no heart rhythm) on cardiac monitor ... we determined no further measures at 0900." Record review revealed time of death as 0900 on 02/16/2024.

Review on 08/22/2024 at 1638 of the CSU video footage revealed Pt#21 entered the room at 0122. Pt#21 positioned himself on his right side in the bed at 0125. The video footage revealed Pt#21 was in the bed, with noted rise and fall of the back and periodic movement from 0125 until 0544. The patient was lying in a prone (on stomach, face down) position on the bed and appeared to be having seizure-like activity (stiffening and abrupt twitching of the body) beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed no staff in Pt#21's room from 0122 through 0852 (7 hours and 30 minutes). A Nursing Assistant (NA#1) entered Pt#21's room at 0852 (2 hours and 55 minutes after breathing appeared to stop on video review). Review of the video revealed at 0853 NA#1 placed a hand on Pt#21's upper body, exited the room, re-entered the room with the light turned on, looked at the patient, walked to the door and motioned for someone to come to the room. At 0854, a Paramedic (Medic#2) and a Psychiatric Physician Assistant (PA#3) entered the room and assessed the patient. The video revealed an ED Provider (MD#4) and an ED PA (PA#5) entered the room at 0855 and assessed the patient. Pt#21 was transferred to a stretcher and removed from the room by PA#5 and a Registered Nurse (RN#6) at 0857.

Interview on 08/23/2024 at 0940 with NA#7 revealed Pt#21 arrived in the CSU late at night. Interview revealed patients were primarily monitored by video camera in the CSU. NA#7 revealed some patients ask not to be disturbed when sleeping but recalled Pt#21 did not request to not be disturbed that night. Interview revealed the typical process was to physically check patients if no movement was noted on video camera for about one hour. NA#7 recalled no need to physically check Pt#21 during the night.

Interview on 08/22/2024 at 1450 with NA#1 revealed NA#1 thought Pt#21 was sleeping on the morning of 02/16/2024. NA#1 revealed the typical process for patients admitted during the night was to allow the patients to rest in the morning. NA#1 revealed constant waking caused psychiatric patients to become irritated. NA#1 revealed the change of shift report from Medic#8 was "disjointed" because Medic#8 was working in the main ED during the night and was pulled to CSU at some point during early morning. Interview revealed that upon entering Pt#21's room with a breakfast tray, NA#1 noticed the patient's face was in the pillow and did not see rise and fall of the chest. Interview revealed NA#1 then called Medic#2 and PA#3 for help. NA#1 revealed fifteen-minute checks were completed by looking at the patient on the monitor screen every fifteen minutes. Interview revealed each CSU room had a camera, and patients were monitored by camera from the nurse's station. NA#1 stated there was not enough staff in the CSU to watch the camera constantly.

Interview on 08/22/2024 with PA#5 revealed MD#4 and PA#5 were called to Pt#21's room on the morning of 02/16/2024 by the behavioral health staff. Interview revealed upon PA#5's arrival to the room, Pt#21 was "blue" and appeared to have "been that way for a while."

Interview on 08/21/2024 at 1534 with MD#4 revealed MD#4 was called to the CSU to evaluate an unresponsive patient on the morning of 02/16/2024. Interview revealed that upon arrival to Pt#21's room, MD#4 noted the patient was on his stomach, had no pulse or spontaneous respirations, was mottled, and the patient's skin tone was dusky gray. Interview revealed Pt#21 had no signs of life and determined CPR (cardiopulmonary resuscitation) was not indicated. Interview revealed the patient was placed on a cardiac monitor to verify there was no pulse. MD#4 stated there was no way to know how long Pt#21 had been deceased.

The day shift Charge Nurse (RN#6) and Medic#8 were not available for interview.

In summary, video review revealed Pt#21 was placed in the CSU on 02/16/2024 at 0122. Review of the CSU video footage revealed the patient was lying in a prone (on stomach face down) position on the bed and appeared to be having seizure-like activity beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed the staff were in Pt#21's room at 0852 (2 hours and 55 minutes after breathing appeared to stop on video review) and found Pt#21 pulseless, with no respirations. Review of the Observation Record revealed documentation for patient observation every fifteen (15) minutes; however, video review revealed no staff entered Pt#21's room from 0122 through 0852 (7 hours and 30 minutes). Record review revealed that the last nursing assessment was completed on 02/16/2024 at 0033, prior to the patient entering the CSU. Pt#21 was pronounced dead at 0900.



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2. Review on 08/28/2024 of the hospital's documentation titled "Best Practices for Cleaning in Behavioral Health Units (BHUs) Effective Date 8.01.17" revealed "Behavioral Health Units (sometimes referred to as psychiatric units) are areas of the hospital where patients with various mental health disorders receive care. The behavioral health unit (BHU) exists to provide a safe, secure place where these patients can receive proper treatment ....Patients in these units may be confused or unaware of their surroundings. In some cases, they are a potential risk for harming themselves or others. If you work in one of these units, it's important to be aware of your surroundings at all times, and to understand how best to keep yourself, co-workers, and patients safe ....Prior to entering a Behavioral Health Units (BHUs) ...Before entering the unit, ensure all team members are properly trained and that they can demonstrate all required competencies ....Only a small number of highly trained and competent team members should be given access. Review revealed "Cleaning Procedures ...Housekeeping carts, chemicals, equipment, and supplies should never be left unattended ....Never give items to patients without asking the patient's nurse first." Continued review of the hospital's documentation titled "Housekeeping Cart Setup" Named Hospital revealed items to the exterior of the housekeeping cart included "High Duster, Lobby Broom, Micromop Sticks and Doodlebug (scrubber with a handle) with stick. Review revealed "Housekeeping Cart Requirements ...When possible, housekeeping carts should be stored in a secured area within the unit."

Review on 08/28/2024 at 1018 of the video recording of the locked behavioral health area of the ED (CSU-Crisis Stabilization Unit) with the hospital SM #19 and the EDAD #10 for 08/16/2024 7a-7p revealed at 1108 an EVST (Environmental Services Technician) #22 entered the locked behavioral health area of the ED from the administration hallway entrance with a housekeeping cart. Continued review revealed at 1111 the housekeeping staff was cleaning the inside ED room number 2 and the cart was in the hallway unattended. Review revealed several long items extended from the cart, that appeared to be at least 4 broom and or mop handles. EVST #22 exited room number 2 and entered the bathroom across the hall. The cart was left unattended and the patient from room 6 walked up to the cart in the hallway and stood within reach of the cart. EVST #22 exited the bathroom and the cart was moved around the corner to the dayroom hallway. EVST#22 entered the bathroom and the cart was left unattended in the dayroom hallway. Review revealed there were 2 patients sitting within reach of the unattended cart. Review revealed EVST #22 exited the bathroom and handed a black unidentified object to one of the patients sitting near the cart in the hallway.

Interview on 08/28/2024 at 1513 with EDAD #10 revealed EVS (Environmental Services) staff would not enter the locked behavioral health area of the ED unless they were called and asked into the unit. Interview revealed there was a schedule for the EVS staff to clean the bathrooms in the CSU. EDAD #10 revealed there was a concern regarding EVST #22 leaving the housekeeping cart unattended and the patient standing within reach of the cart.

Interview on 08/28/2024 at 1532 with EVSD #20 (Environmental Services Director) and EVSS #21 (Environmental Services Supervisor) revealed EVST #22 was the primary staff assigned to the locked behavioral health area of the ED. EVSS #21 revealed education and cleaning of the of the locked behavioral health area of the ED occurred during orientation. Interview revealed when the locked behavioral health area of the ED was cleaned, the cleaning cart was to be kept outside the locked behavioral health area entrance door from the main Emergency Department. Continued interview revealed that if housekeeping services were needed in the CSU, the "Current practice is to take the cart into the patient's unoccupied room and the door would be locked for cleaning. The bathrooms do not lock and the patients are in their rooms away from the bathrooms." EVSS #21 confirmed "The cart should have been in the patient's room and room locked."EVSD #20 and EVSS #21 stated the cleaning cart needed to be secured away from the patients.

Request was made for an interview with EVST #22 on 08/28/2024 at 1515. EVST #22 was not available for interview.

Based on policy review, job description review, medical record review, video footage review and staff interviews, the hospital's nursing staff failed to supervise and provide oversight of care for a behavioral health patient.

The findings include:

The hospital failed to ensure nursing staff was available to supervise, assess, and monitor a behavioral health patient in a locked behavioral health area of the Emergency Department (ED) for 1 of 1 sampled behavioral health patients that expired in the ED.

~ Cross refer to Nursing Supervision of Nursing Care Standard: Tag 0395

Based on policy reviews, medical record review, video footage review, job description review and staff interviews, the hospital failed to ensure nursing staff was available to supervise, assess, and monitor a behavioral health patient in a locked behavioral health area of the Emergency Department (ED) for 1 of 1 sampled behavioral health patients that expired in the ED (Patient#21).

The findings include:

Review on 08/23/2024 of the hospital policy "Guidelines for the Behavioral Health Patient in the Emergency Department and the Emergency Department Crisis Stabilization Unit (CSU)," effective 06/2022, revealed, "... F. The CSU nursing staff should monitor patient behavior and document significant findings in the patient's medical record ... L ... If, during the course of the patient CSU admission, any medical issues arise, the behavioral health nurse ... may request the ED physician on duty during that time to provide additional clinical support ..."

Review on 08/23/2024 of the hospital policy "Nursing Documentation of Patient Care in the Emergency Department," effective 06/2023, revealed, "... 6. Reassessments will be documented as a note in the patient record ..."

Medical record review revealed Patient#21 (Pt#21), a 30-year-old male, who presented to the emergency department (ED) by ambulance (EMS-Emergency Medical Services) on 02/15/2024 at 2151 with complaints of hallucinations and suicidal ideations. Review of the ED Provider Note, on 02/15/2024 at 2222, revealed Pt#21 reported suicidal ideation for one (1) year with a plan to take all his medications at once. Review of the nursing assessment at 0033 revealed, "No Respiratory Distress ... Cardiovascular: Regular Rate, Pulses Strong ..." Review of the Observation Record revealed Pt#21 arrived in the CSU at 0121 (video review showed 0122). Review of the Nursing Assistant (NA) Note on 02/16/2024 at 0853 revealed, "I writer went to patient room to give him breakfast (sic) tray. Patient was laying on his stomach with face in the pillow. I called his name several times and no answer. I shook patient and no response. I put my hand on patient (sic) back and felt no rise. I turned light on and did not see patient back rise. I motioned to psych (psychiatric) provider to come to the room and called medic (paramedic) to come to the room. Psych provider came in the room and saw patient did not have a pulse ..." Review of the Registered Nurse (RN) Note at 0900 revealed, "called code blue to CSU, pt found to be not breathing, pulseless, no sign of life, pt was facedown (sic) in prone position, already had pooling of blood, it appears pt had been this way for some time, early signs of rigor (stiffening of the joints and muscles) and stiffness, monitor shows asystole, MD (doctor) pronounced pt deceased." Review of the ED Provider Note at 0906 revealed, "... Pt was laying (sic) face down on bed with face buried in pillow. I turned him on his side, no breathing noted, pulseless. Cool to touch, noted with lividity (bluish-purple discoloration of the skin that occurs after death). No heart sounds ... I told staff I did not feel we needed to start CPR (cardiopulmonary resuscitation), we confirmed asystole (no heart rhythm) on cardiac monitor ... we determined no further measures at 0900." Record review revealed time of death as 0900 on 02/16/2024. Review failed to reveal evidence of a Nursing Assessment or a Nurse's Note after 0033, until Pt#21's time of death at 0900.

Review on 08/22/2024 at 1638 of the CSU video footage revealed Pt#21 entered the room at 0122. The video footage revealed Pt#21 was in the bed, with noted rise and fall of the back and periodic movement from 0125 until 0544. The patient was lying in a prone (on stomach, face down) position on the bed and appeared to be having seizure-like activity (stiffening and abrupt twitching of the body) beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed no staff in Pt#21's room from 0122 through 0852 (7 hours and 30 minutes).

Review on 08/23/2024 of the Staff Registered Nurse Job Description for the ED revealed, "... Accountabilities ... 1. ... b. Makes complete and appropriate nursing assessment upon patient admission, and as frequently as warranted by patient's condition ... 7. ... a. Ensures the adequacy of care provided, and adherence to patient care policies, procedures and techniques by assigned team members, immediately intervening to correct deficiencies ... b. Ensures that patient care assignments are within the team member's level of skill and competence ..."

Interview on 08/23/2024 at 1315 with the ED Assistant Director (EDAD#10) confirmed Medic#9 called out on 02/15/2024 for the night shift. Interview revealed NA#11 replaced Medic#9 in the CSU.

Interview on 08/23/2024 at 0940 with NA#7 revealed NA#7 worked with NA#11 in the CSU on the night of 02/15/2024. NA#7 revealed there was no RN assigned to work in the CSU for night shift on 02/15/2024. Interview revealed the CSU was occasionally staffed with two NAs and no RN or Paramedic. NA#7 revealed the NAs would have to call the ED Charge Nurse for assistance when an RN was needed.

Interview on 08/23/2024 at 1006 with NA#11 confirmed NA#7 and NA#11 were the two clinical staff who worked in the CSU on the night of 02/15/2024. Interview revealed NA#11 left around 0600 on 02/16/2024 and was relieved by Medic#8, who was working in the main area of the ED. Interview revealed the CSU was sometimes staffed with two NAs when the ED was low on staff.

Interview on 08/22/2024 at 1450 with NA#1 revealed NA#1 and Medic#2 were the two clinical staff members who worked in CSU for day shift (0700 to 1900) on 02/16/2024. Interview revealed there was no RN assigned to work in the CSU that day.

Interview on 08/23/2024 at 0918 with the night shift Charge Nurse (RN#12) revealed RN#12 did not recall seeing Pt#21 after the patient was transferred to the CSU. RN#12 revealed there no requirement for an RN to work in the CSU.

Interview on 08/27/2024 at 1143 with the ED RN Director (Director#13) revealed the ED Charge Nurse was responsible for assessing patients in the CSU when there was no RN assigned to the unit. Director#13 revealed an RN was required to enter the CSU once per shift to assess patients. Director#13 revealed Paramedics and Nursing Assistants were not able to assess patients.

The day shift Charge Nurse (RN#6) and Medic#8 were not available for interview.

In summary, review of video footage revealed Pt#21 was placed in the CSU on 02/16/2024 at 0122. Review of the CSU video footage revealed the patient was lying in a prone (on stomach face down) position on the bed and appeared to be having seizure-like activity beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed no staff in Pt#21's room from 0122 through 0852 (7 hours and 30 minutes). Pt#21 was pronounced dead at 0900. Record review revealed that the last nursing assessment was completed on 02/16/2024 at 0033, prior to the patient entering the CSU. Review revealed there were two (2) nursing assistants assigned to work in the locked Emergency Department behavioral health area (CSU) on 02/15/2024 from 7pm to 7am. The investigation failed to reveal evidence of nursing presence in the CSU to assess or supervise care for Pt#21 after 0122 on 02/16/2024.

Based on policy reviews, medical record review, video footage review and staff and provider interviews,the hospital failed to have effective emergency services to meet the needs of behavioral health patients that presented to the Emergency Department.

The findings include:

Emergency Department (ED) staff failed to evaluate patient care by failing to monitor, reassess and address a patient's change in condition and subsequent death for 1 of 1 sampled behavioral health patients that expired in the ED (Patient#21).

~ Cross refer to §482.55 Emergency Services Standard: Tag 1104

Based on policy reviews, medical record review, video footage review and staff and provider interviews, Emergency Department (ED) staff failed to evaluate patient care by failing to monitor, reassess and address a patient's change in condition and subsequent death for 1 of 1 sampled behavioral health patients that expired in the ED (Patient#21).

The findings include:

Review on 08/23/2024 of the hospital policy "Suicide Risk and Assessment Precautions," effective 05/2023, revealed, "... In the secure behavioral health units ... close observation every 15 min (fifteen minutes) ... Definitions: ... "Close observation" regular and ongoing observation with a minimum of every 15-minute checks."

Review on 08/23/2024 of the hospital policy "Guidelines for the Behavioral Health Patient in the Emergency Department and the Emergency Department Crisis Stabilization Unit (CSU)," effective 06/2022, revealed, "... F. The CSU nursing staff should monitor patient behavior and document significant findings in the patient's medical record ... L ... If, during the course of the patient CSU admission, any medical issues arise, the behavioral health nurse ... may request the ED physician on duty during that time to provide additional clinical support ..."

Medical record review revealed Patient#21 (Pt#21), a 30-year-old male, who presented to the emergency department (ED) by ambulance (EMS-Emergency Medical Services) on 02/15/2024 at 2151 with complaints of hallucinations and suicidal ideations. Review of the ED Provider Note, on 02/15/2024 at 2222, revealed Pt#21 reported suicidal ideation for one (1) year with a plan to take all his medications at once. Physician Orders were placed on 02/15/2024 at 2313 for "ED Behavioral Health Holding" (to keep the patient in the ED until a psychiatric evaluation occurs) and to obtain vital signs every shift. At 2314, a Physician Order was placed for observation every 15 minutes. Review of the Rapid Initial Screening on 02/16/2024 at 0028 revealed the following vital signs: blood pressure 124/77, heart rate 101, respirations 18, and an oxygen level of 100%. Review of the nursing assessment at 0033 revealed, "No Respiratory Distress ... Cardiovascular: Regular Rate, Pulses Strong ..." Review of the Observation Record revealed Pt#21 arrived in the CSU (Crisis Stabilization Unit - locked unit attached to the Emergency Department) at 0121 (video footage showed 0122). The CSU observation record revealed documentation of every 15 minute patient observations, beginning on 02/16/2024 at 0130 until 0845. Review of the Nursing Assistant (NA) Note on 02/16/2024 at 0853 revealed, "I writer went to patient room to give him breakfast (sic) tray. Patient was laying on his stomach with face in the pillow. I called his name several times and no answer. I shook patient and no response. I put my hand on patient (sic) back and felt no rise. I turned light on and did not see patient back rise. I motioned to psych (psychiatric) provider to come to the room and called medic (paramedic) to come to the room. Psych provider came in the room and saw patient did not have a pulse ..." Review of the Registered Nurse (RN) Note at 0900 revealed, "called code blue to CSU, pt found to be not breathing, pulseless, no sign of life, pt was facedown (sic) in prone position, already had pooling of blood, it appears pt had been this way for some time, early signs of rigor (stiffening of the joints and muscles) and stiffness, monitor shows asystole, MD (doctor) pronounced pt deceased." Review of the ED Provider Note at 0906 revealed, "... Pt was laying (sic) face down on bed with face buried in pillow. I turned him on his side, no breathing noted, pulseless. Cool to touch, noted with lividity (bluish-purple discoloration of the skin that occurs after death). No heart sounds ... I told staff i did not feel we needed to start CPR (cardiopulmonary resuscitation), we confirmed asystole (no heart rhythm) on cardiac monitor ... we determined no further measures at 0900." Record review revealed time of death as 0900 on 02/16/2024.

Review on 08/22/2024 at 1638 of the CSU video footage revealed Pt#21 entered the room at 0122. Pt#21 positioned himself on his right side in the bed at 0125. The video footage revealed Pt#21 was in the bed, with noted rise and fall of the back and periodic movement from 0125 until 0544. The patient was lying in a prone (on stomach, face down) position on the bed and appeared to be having seizure-like activity (stiffening and abrupt twitching of the body) beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed no staff in Pt#21's room from 0122 through 0852 (7 hours and 30 minutes). A Nursing Assistant (NA#1) entered Pt#21's room at 0852 (2 hours and 55 minutes after breathing appeared to stop on video review). Review of the video revealed at 0853 NA#1 placed a hand on Pt#21's upper body, exited the room, re-entered the room with the light turned on, looked at the patient, walked to the door and motioned for someone to come to the room. At 0854, a Paramedic (Medic#2) and a Psychiatric Physician Assistant (PA#3) entered the room and assessed the patient. The video revealed an ED Provider (MD#4) and an ED PA (PA#5) entered the room at 0855 and assessed the patient. Pt#21 was transferred to a stretcher and removed from the room by PA#5 and a Registered Nurse (RN#6) at 0857.

Interview on 08/23/2024 at 1315 with ED Assistant Director (EDAD#10) revealed Medic#9 called out on 02/15/2024 for the night shift. Interview revealed NA#11 replaced Medic#9 in the CSU.

Interview on 08/23/2024 at 0940 with NA#7 revealed NA#7 worked with NA#11 in the CSU on the night of 02/15/2024. NA#7 revealed there was no RN assigned to work in the CSU for night shift on 02/15/2024. NA#7 revealed the NAs would have to call the ED Charge Nurse for assistance when an RN was needed. Interview patients were primarily monitored by video camera in the CSU. Interview revealed the typical process was to physically check patients if no movement was noted on video camera for about one hour. NA#7 recalled no need to physically check Pt#21 during the night.

Interview on 08/23/2024 at 0918 with the night shift Charge Nurse (RN#12) revealed RN#12 did not recall seeing Pt#21 after the patient was transferred to the CSU.

Interview on 08/22/2024 at 1450 with NA#1 revealed NA#1 thought Pt#21 was sleeping on the morning of 02/16/2024. Interview revealed that upon entering Pt#21's room with a breakfast tray, NA#1 noticed the patient's face was in the pillow and did not see rise and fall of the chest. Interview revealed NA#1 then called Medic#2 and PA#3 for help. NA#1 revealed fifteen-minute checks were completed by looking at the patient on the monitor screen every fifteen minutes. Interview revealed each CSU room had a camera, and patients were observed on the video monitor located in the nurse's station.

Interview on 08/22/2024 with PA#5 revealed MD#4 and PA#5 were called to Pt#21's room on the morning of 02/16/2024 by the behavioral health staff. Interview revealed upon PA#5's arrival to the room, Pt#21 was "blue" and appeared to have "been that way for a while."

Interview on 08/21/2024 at 1534 with MD#4 revealed MD#4 was called to the CSU to evaluate an unresponsive patient on the morning of 02/16/2024. Interview revealed that upon arrival to Pt#21's room, MD#4 noted the patient was on his stomach, had no pulse or spontaneous respirations, was mottled, and the patient's skin tone was dusky gray. Interview revealed Pt#21 had no signs of life and determined CPR (cardiopulmonary resuscitation) was not indicated. Interview revealed the patient was placed on a cardiac monitor to verify there was no pulse. MD#4 stated there was no way to know how long Pt#21 had been deceased.

Interview on 08/27/2024 at 1143 with the ED RN Director (Director#13) revealed the ED Charge Nurse was responsible for assessing patients in the CSU when there was no RN assigned to the unit. Director#13 revealed an RN was required to enter the CSU once per shift to assess patients. Director #13 revealed Paramedics and Nursing Assistants were not allowed to assess patients.

Interview on 08/23/2024 at 1600 by Director#13, CEO#14, Director#15 (Corporate Quality), and Director#16 (Quality Director) revealed ED staff focused on "safety checks" every fifteen minutes but did not monitor Pt#21 for signs of life. The interview revealed there was no RN present while Pt #21 was in the CSU.

The day shift Charge Nurse (RN#6) and Medic#8 were not available for interview.

In summary, review of video footage revealed Pt#21 was placed in the CSU on 02/16/2024 at 0122. Review of the CSU video footage revealed the patient was lying in a prone (on stomach face down) position on the bed and appeared to be having seizure-like activity beginning at 0544 with rapid breathing through 0557 (13 minutes). Breathing appeared to stop at 0557. Video review revealed ED staff were in Pt#21's room at 0852 (2 hours and 55 minutes after breathing appeared to stop on video review) and found Pt#21 pulseless, with no respirations. Review of the Observation Record revealed documentation for patient observation every fifteen (15) minutes; however, video review revealed no staff entered Pt#21's room from 0122 through 0852 (7 hours and 30 minutes). Record review revealed that the last nursing assessment was completed on 02/16/2024 at 0033, prior to the patient entering the CSU. The investigation failed to reveal evidence of ED RN presence in the CSU to assess or supervise care for Pt#21 after 0122. Pt#21 was pronounced dead at 0900.


NC00213810, NC00207235, NC00212047, NC00208438, NC00211845, NC00206420