HospitalInspections.org

Based on document review and staff interview, the hospital's administrative staff failed to ensure the grievance staff provided the patient with written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance that included the date of the completion of the investigation for 5 of 5 grievances reviewed (Patient #2, Patient #9, Patient #10, Patient #11, and Patient #12). Failure to provide the results of the hospital staff's investigation of the grievance that included the date of the completion could result in grievants not knowing the completion date of the investigation, and believing the hospital did not seriously investigate the complaint. The hospital's administrative staff identified a current hospital census of 127 patients at the beginning of the survey.

Findings include:

1. Review of the policy "Grievance Procedure For Patients," revised 01/2019, failed to include the requirement that the grievance staff provided the patient with written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance that included the date of the completion of the investigation.

2. Review of closed grievances on 8/6/2020 revealed:

a. In a letter to the grievant, for a grievance filed on 2/3/2020 involving Patient #2, the letter lacked documentation of the results of the hospital's investigation into the grievance and the date the hospital staff completed their investigation into the grievance.

b. In a letter to the grievant, for a grievance filed on 2/23/2020 involving Patient #9, the letter lacked documentation of the results of the hospital's investigation into the grievance and the date the hospital staff completed their investigation into the grievance.

c. In a letter to the grievant, for a grievance filed on 2/25/2020 involving Patient #10, the letter lacked documentation of the results of the hospital's investigation into the grievance and the date the hospital staff completed their investigation into the grievance.

d. In a letter to the grievant, for a grievance filed on 7/15/2020 involving Patient #11, the letter lacked documentation of the results of the hospital's investigation into the grievance and the date the hospital staff completed their investigation into the grievance.

e. In a letter to the grievant, for a grievance filed on 6/12/2020 involving Patient #12, the letter lacked documentation of the results of the hospital's investigation into the grievance and the date the hospital staff completed their investigation into the grievance.


3. During an interview on 8/18/2020 at 2:15 PM, the Director of Quality/Accreditation and Patient Safety acknowledged the letters to the grievants lacked written notice of the hospital's decision regarding the grievance, including the steps taken on the behalf of the patient to investigate the grievance and the date that the hospital staff concluded their investigation of the grievance.

I. Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff adequately supervised
- 1 of 1 patient who died during their hospitalization in the Behavioral Health Unit (Patient #1)
- 6 of 6 patients on suicide precautions who were not monitored in the BHU area where ligature risks were present (Patient #8)
- 5 of 6 patients identified as having suicidal thoughts with suicide attempts or plans to commit suicide in the Emergency Room (Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6).

Please refer to A-0395 for additional information. The cumulative effect of these failures and deficient practices resulted in the hospital staff's inability to ensure patients received safe nursing services.



II. During the course of the investigation of complaints 92572-C and 92576-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis that placed the health and safety of patients at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23). The hospital staff failed to provide adequate supervision of a patient on 1 to 1 observation in the Behavioral Health Unit, which resulted in the nursing staff not identifying the patient was deceased until an unknown about of time after the patient died.

1. Prior to an event on 08/03/2020, the Administrative staff failed to develop and implement a corrective action plan to ensure the nursing staff physically observe a patient on 1:1 monitoring and all patients during the 15 minute safety rounds and did not rely on camera video monitors to substitute for the nursing staff physically observing the patients.

2. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 08/11/2020 at 5:00 PM. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the Immediate Jeopardy prior to the exit date of the complaint investigation. A condition level deficiency remained for the Condition of Participation for Nursing Services (42 CFR 482.23).

The corrective action plan included:

a. The Chief Nursing Officer, the Vice President Quality & Integration, and the Manager of the Behavioral Health Unit immediately reviewed all Behavioral Health patients listed as 1:1 to ensure the patients were observed continuously, which was implemented on 08/11/2020. Immediate education of staff that they understood and would comply with the One on One policy prior to being allowed to work on the unit. Ligature risks on the unit were addressed. The hospital staff addressed and remedied the ligature risks they could on 8/12/2020. The addition of a camera monitoring tech in the Behavioral Health Unit to monitor the camera at all times until ligature risk and fire door issue is resolved. Camera tech added to the staffing on 08/11/2020. Daily monitoring of compliance implemented on 08/12/2020.

b. The Chief Nursing Officer reviewed the 1:1 observation policy with no changes made to the policy. Camera monitoring would not replace performing in-person rounding and was to be a supplement to the rounding process.

The following Condition level deficiency remained for the Condition for Nursing Services (42 CFR 482.23).

I. Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff provided adequate supervision to 1 of 1 patient on 1:1 observation who died during their hospitalization in the inpatient Behavioral Health Unit (Patient #1). Failure of the nursing staff to adequately supervise and observe Patient #1, including 1:1 supervision, resulted in the nursing staff not identifying the patient was deceased until after an unknown amout of time after the patient died during their hospitalization in the Behavioral Health Unit. The hospital's administrative staff identified 10 inpatients in the hospital's behavioral health unit at the beginning of the survey.

Findings include:

1. Review of the policy "One to One Observation (1:1 Precautions in Non-Suicidal Patients)," revised 03/2019, revealed in part, "To provide guidelines for one to one observation of patients in a consistent and safe manner. To provide patients with a supervised environment so that the patient's condition does not result in self harm or harm to others... A One to One (1:1 precautions) order shall be entered in the electronic medical record (EMR) as a nursing intervention... Staffing Expectations: ... Staff may not leave the room without a replacement present ... Staff must be within arms length of the patient...."

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

a. the hospital staff admitted Patient #1 to the hospital's inpatient behavioral health unit on 6/14/2020 for treatment of auditory and visual hallucinations, with paranoia and delusions.

b. A nursing order, entered on 7/17/20 at 6:54 PM, indicated Patient #1 required 1:1 observation by Contracted Security Service (CSS) F (an outside company which provided observation services to potentially violent patient in the hospital's inpatient behavioral health unit) and 1:1 observation by a CNA at all times.

c. Registered Nurse (RN) C documented they administered 2 mg Lorazepam (a medication to produce a calming effect) to Patient #1 via injection at 12:20 PM on 8/3/2020.

d. The hospital's medical staff pronounced Patient #1's death on 8/3/2020 at 1:29 PM. The documentation in the medical record indicated the hospital staff last saw Patient #1 alive at 12:20 PM, when RN C documented they administered the Lorazepam to Patient #1 (69 minutes earlier).

e. The documentation in the medical record revealed the nursing staff monitored Patient #1 using a camera video monitor located at the nursing station, and did not provide 1:1 observation (staff within arm's reach of Patient #1) per the hospital's policy.


3. Review of the "Daily Patient Rounds" sheet for 8/3/2020 revealed:

a. CNA A documented they performed safety rounds every 15 minutes and documented they visually observed Patient #1 in Patient #1's room from 8:15 AM to 11:15 AM.

b. RN C documented they performed safety rounds every 15 minutes and documented they visually observed Patient #1 in Patient #1's room from 11:30 AM to 12:45 PM.



4. During an interview on 8/10/2020 at 2:05 PM, CNA A revealed on 8/3/2020 they were assigned to observe Patient #1 on 1:1 observation, with assistance from a CSS F staff member, from 6:00 AM to 2:00 PM. CNA A indicated the expectation was, when providing 1:1 observation to a patient, the nursing staff had to stay in the room with the patient at all times, unless the staff member went on a break.

CNA A provided 1:1 observation of Patient #1 in their room on 8/3/2020 until CNA A went on their lunch break. After CNA A returned from their lunch break, CNA A saw RN C go into Patient #1's room with a machine to check Patient #1's vital signs. CNA A then went to the camera monitors in the nurses' station and observed Patient #1 was still in their room. CNA A documented Patient #1 was in their room at 1:00 PM on the Daily Patient Rounds sheet, due to observing Patient #1 in their room using the camera monitors. CNA A acknowledged, due to the hospital utilizing pre-printed times on the Daily Patient Rounds sheet, they could have observed Patient #1 in their room anytime from 1:00 PM to 1:15 PM, and not exactly at 1:00 PM.


5. Review of CNA A's time card for 8/3/2020 revealed CNA A clocked out at 12:06 PM to start their lunch break. CNA A then clocked back into work status from their lunch break at 12:35 PM (29 minutes later).


6. During an interview on 8/10/2020 at 4:20 PM, RN C revealed Patient #1 was on 1:1 observation due to Patient #1's behavior. Security Guard E was present in Patient #1's room when RN C administered the Lorazepam injection to Patient #1 at 12:20 PM. Patient #1 did not resist receiving the injection. RN C last saw Patient #1 alive at approximately 12:30 PM, after RN C administered the Lorazepam injection to Patient #1.

When CNA A went to their lunch break on 8/3/2020, Patient #1 was sleeping. CSS F's Security Guard E was outside Patient #1's room when CNA A went to their lunch break on 8/3/2020. RN C instructed Security Guard E to observe Patient #1 via the video camera monitors in the nurses' station (leaving Patient #1 without a staff member physically present to continuously observe them from arm's length).

Infectious Disease (ID) Physician B (a physician with specialized training in the treatment of infectious diseases) came to the inpatient behavioral health unit to evaluate Patient #1. RN C escorted ID Physician B to Patient #1's room at approximately 1:15 PM. When RN C and ID Physician B entered Patient #1's room, ID Physician B attempted to speak to Patient #1, but Patient #1 did not respond. Patient #1 was laying on their stomach, which was how Patient #1 normally slept. They rolled Patient #1 over and could tell Patient #1 was dead, as they observed Patient #1's lips were blue and the tips of Patient #1's fingers were blue.

ID Physician B attempted to start CPR on Patient #1 by performing a few chest compressions to check for any movement from Patient #1. Patient #1 did not move. RN C left the room to summon other staff to assist with attempting to resuscitate Patient #1 and get a machine to check Patient #1's vital signs. When RN C attempted to check Patient #1's blood pressure, the machine could not read Patient #1's blood pressure. When an intensivist physician (a physician with specialized training to treat patients in a hospital's ICU) arrived, the intensivist physician looked at ID Physician B, informed ID Physician B and RN C that Patient #1 had died, they could not save Patient #1, and told the other staff responding to resuscitate Patient #1 that they did not need to even enter Patient #1's room.


7. During an interview on 8/10/2020 at 3:00 PM, Infectious Disease (ID) Physician B revealed they arrived on the inpatient behavioral health unit at approximately 1:20 PM on 8/3/2020. ID Physician B went into Patient #1's room with RN C. Patient #1 was laying face down on a mattress on the floor. Patient #1's forehead was on a pillow, but the patient's face was not directly on the mattress or pillow. ID Physician B attempted to speak to Patient #1, but Patient #1 did not respond.

RN C helped ID Physician B roll Patient #1 onto their back. Patient #1 was not breathing and Patient #1's lips were blue. ID Physician B instructed RN C to summon other hospital staff to assist in attempting to resuscitate Patient #1. ID Physician B performed a few chest compressions, but ID Physician B could clearly tell Patient #1 was not breathing and ID Physician B could not identify a pulse on Patient #1's body. ID Physician B listened with a stethoscope to hear Patient #1's heart beat or Patient #1 breathing. Patient #1's body was cool to the touch. ID Physician B shined a pen light into Patient #1's eyes and noticed Patient #1's pupils were fixed and dilated, with no change when ID Physician B shined the light into Patient #1's eyes.

When ID Physician B finished examining Patient #1, the intensivist physician had arrived at Patient #1's room, along with other hospital staff present to attempt to resuscitate Patient #1. The intensivist physician examined Patient #1 using a stethoscope to listen for heart and lung sounds on Patient #1 and checked to see if Patient #1's pupils for a reaction to the pen light. The intensivist determined Patient #1 was dead. The responding staff did not perform any further resuscitation efforts for Patient #1, including hooking Patient #1 up to the defibrillator, as Patient #1 did not exhibit any signs of life.


8. During an interview on 8/12/2020 at 10:10 AM, Contracted Security Service (CSS) F's Security Guard E revealed they were assigned to assist the nursing staff to provide 1:1 observation for Patient #1 on 8/3/2020. Security Guard E's role was to ensure the safety of the nursing staff. If the nursing staff were in Patient #1's room, Security Guard E would stay in Patient #1's room, in case Patient #1 became aggressive. The nursing staff did not indicate at any time on 8/3/2020 that Patient #1 did not require 1:1 observation (i.e.: Patient #1 was still on 1:1 observation).

CNA A and Security Guard E were providing Patient #1 with 1:1 observation in Patient #1's room when RN C came to Patient #1's room. RN C asked CNA A if CNA A needed to take their lunch break. CNA A indicated they would take their lunch break and left Patient #1's room. RN C instructed Security Guard E to watch Patient #1 on the camera monitors at the nursing station, since Patient #1 was asleep (thus leaving no hospital or contracted staff monitoring Patient #1 within arm's length of Patient #1).

About 5 minutes after Security Guard E and CNA A left Patient #1's room, Patient #1 needed medication. RN C prepared an injection for Patient #1. Security Guard E escorted RN C to Patient #1's room. RN C attempted to wake up Patient #1 to let them know RN C was going to give Patient #1 an injection of medication (Lorazepam). Patient #1 was snoring when RN C spoke to Patient #1. RN C administered the injection to Patient #1 and left without any issues. RN C and Security Guard E left Patient #1's room.

Security Guard E went back to the nurses' station to continue to monitor Patient #1 through the camera monitors. During the next 30 minutes, none of the hospital staff entered Patient #1's room. After approximately 30 minutes, Security Guard E escorted a physician and RN C to Patient #1's room. The physician and RN C attempted to awaken Patient #1 without success (as Patient #1 had died in the interim).


9. During an interview on 08/11/2020 at 10:10 AM, the Behavioral Health Unit Nurse Manager acknowledged the nursing staff needed to provide 1:1 observation to Patient #1 on 8/3/2020. The Behavioral Health Unit Nurse Manager acknowledged the hospital's 1:1 observation policy required the hospital staff must stay within arm's length of Patient #1 at all times. The Behavioral Health Unit Nurse Manager also acknowledged the nursing staff failed to provide 1:1 observation to Patient #1 at all times on 8/3/2020 (when Patient #1 died and the staff did not immediately notice Patient #1's death, as they did not provide continuous in-person monitoring of Patient #1).




II. Based on document review, observations, and staff interviews, the hospital's administrative staff failed to ensure the nursing staff provided adequate supervision to 6 of 6 patients on suicide precautions who were not monitored in the Behavioral Health Unit (BHU) area where ligature risks were present (Patient #8, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17). Failure to monitor patients on suicide precautions where ligature risks were present could potentially provide a point of attachment for a device used for patient strangulation or hanging and result in patient deaths or other life-threatening conditions. The hospital's administrative staff identified 10 inpatients in the hospital's behavioral health unit at the beginning of the survey.

Findings include:

1. Observations in the Behavioral Health Unit on 08/06/2020 from 9:40 AM to 9:55 AM, with the Behavioral Health Unit Nurse Manager revealed the following:

- TV Lounge/Group Room with 1 of 1 set of double doors with 3 exposed hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame.

- Library/Activity Room with 1 of 1 storage room door with 3 exposed hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame. Also 2 of 2 small doors with 1 exposed hinge on the top of each door. The hinges extended approximately 1-inch from the door frame

- 1 of 1 metal door closer mounted on the upper interior surface on each of 2 doors (double doors) in the hallway. The set of double doors were in the open position and the metal door closers formed a triangle shape that extended approximately 6 inches into the door opening to the hallway. A door closer is a mechanical device that closes a door after it is opened.

The door hinges may be utilized as ligature points and sufficient areas for attachment of a hanging device that a patient could use to hang themselves in an unmonitored situation.


2. Observations in the Behavioral Health Unit on 08/11/2020 from 11:15 AM to 11:45 AM, with the Behavioral Health Unit Nurse Manager and Vice President Quality and Integration revealed

- Patient #8 in the TV Lounge/Group room without staff present to supervise Patient #8 during the timeframe of the observations. The TV Lounge/Group room had 1 of 1 set of double doors with 3 exposed hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame (which created a potential ligature risk for Patient #8 to attempt suicide by hanging themselves from the door hinge).

- Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17 were walking on the unit without direct staff observation or staff assigned to monitor the cameras in the inpatient Behavioral Health unit. The patients walked in a hallway with a set of double doors in the open position, and the metal door closers formed a triangle shape that extended approximately 6 inches into the door opening to the hallway.

3. During an interview on 08/06/2020 during tour from 9:40 AM to 9:55 AM, the Behavioral Health Unit Nurse Manager confirmed a patient could use the door hinges as ligature points and the door hinges and door closers had sufficient area for a patient to attach a hanging device that a patient could use to hang themselves and the door hinges and door closers posed a risk for patients to potentially kill themselves.

4. Review of patient medical records on 8/11/2020 at 11:45 AM with the Behavioral Unit Nurse Manager revealed the admitting diagnosis for Patient #8, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17 was for suicidal ideations and the nursing staff placed the patients on suicide precautions (interventions designed to prevent a patient from committing suicide in the hospital).

5. During an interview on 08/11/2020 at 11:45 AM, the Behavioral Health Unit Nurse Manager revealed they did not assign a staff member to monitor the cameras at the nursing station to ensure patients on suicide precautions did not attempt to commit suicide in the inpatient behavioral health unit or ensure the patients did not attempt to commit suicide with the ligature risks from the door hinges and door closers.




III. Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff provided adequate supervision to 5 of 6 patients in the Emergency Department (Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6) the nursing staff identified that had suicidal thoughts, had specific plans to commit suicide, or had attempted suicide. Failure to monitor patients with suicidal thoughts or suicide attempts could potentially result in the patient potentially attempting suicide in the Emergency Department, potentially resulting in the patients killing themselves in the hospital. The hospital's administrative staff identified approximately 1311 emergency room visits per month.

Findings include:

1. Review of the policy "Suicide (Self-Harm) Risk Screening and Precautions in the Outpatient Settings," revised 10/2018, revealed in part, "... Patients who are identified as a possible suicide risk must have 1:1 observation ... If suicide precautions are initiated, implement interventions to increase patient safety, which may include but not limited to: Place as a 1:1 observation ... Make additional periodic checks for harmful objects... Document 1:1 observation of the patient ... Patient care activities while the patient is on suicide precautions in a 1:1 shall be documented every fifteen (15) minutes."

2. Review of patient emergency room medical records on 08/13/2020 at 8:30 AM and 08/19/2020 at 9:10 AM with the Director of Emergency Room and Ambulatory Services revealed the following:

a. The nursing staff admitted Patient #2 to the Emergency Department on 2/1/2020 at 4:08 PM. Patient #2 had a chief complaint of suicidal thoughts with a very specific suicide plan (an indication Patient #2 strongly intended to commit suicide). Patient #2 planned to place their hands behind their backs, use zip ties to secure their hands together, and use a blanket to hang themselves. Patient #2's medical record lacked documented evidence the nursing staff implemented suicide precautions, including 1:1 observation and checking on Patient #2 every 15 minutes, as required by the hospital's policy.

b. The nursing staff admitted Patient #3 to the Emergency Department on 7/26/20 at 6:42 PM. Patient #3 had a chief complaint of attempting to unsuccessfully kill themselves by hanging that day. Patient #3's medical record lacked documented evidence the nursing staff implemented suicide precautions, including 1:1 observation and checking on Patient #3 every 15 minutes, as required by the hospital's policy.

c. The nursing staff admitted Patient #4 to the Emergency Department on 7/4/2020 at 5:11 AM. Patient #4 had a chief complaint of suicidal thoughts with a specific plan to use their car to kill themselves by intentionally getting into a car accident (an indication Patient #4 strongly intended to commit suicide). Patient #4's medical record lacked documented evidence the nursing staff implemented suicide precautions, including 1:1 observation and checking on Patient #4 every 15 minutes, as required by the hospital's policy.

d. The nursing staff admitted Patient #5 to the Emergency Department on 7/28/2020 at 11:43 AM. Patient #4 had a chief complaint of suicidal thoughts with a specific plan to use their car to kill themselves by jumping off a bridge (an indication Patient #5 strongly intended to commit suicide). Patient #5's medical record lacked documented evidence the nursing staff implemented suicide precautions, including 1:1 observation and checking on Patient #5 every 15 minutes, as required by the hospital's policy.

e. The nursing staff admitted Patient #6 to the Emergency Department on 7/13/2020 at 4:49 AM. Patient #6 had a chief complaint of attempting to unsuccessfully kill themselves by jumping off a bridge that day. Patient #6's medical record lacked documented evidence the nursing staff implemented suicide precautions, including 1:1 observation and checking on Patient #6 every 15 minutes, as required by the hospital's policy.


3. During an interview on 8/19/2020 at 9:10 AM, the Director of Emergency Room and Ambulatory Services acknowledged Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6's medical records indicated the patients either had attempted to kill themselves or had thoughts of killing themselves with very specific plans (an indication the patient strongly intended to commit suicide). The Director of Emergency Room and Ambulatory Services acknowledged the medical records lacked evidence the nursing staff provided 1:1 observation and checked on the patients every 15 minutes, as required by the hospital's policy. The Director of Emergency Room and Ambulatory Services also acknowledged that if the patients' medical record lacked documentation the nursing staff provided 1:1 observation to the patients and checked on the patients every 15 minutes, the hospital lacked evidence the nursing staff provided the supervision these patients required under the hospital's policy.