HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on clinical record reviews (Patients #6, 10, 27), review of hospital documentation, meeting minutes, and interviews, the hospital's governing body failed to ensure that the Chief Executive Officer was responsible for the management of the hospital when the hospital's Chief Administrative Officer (position of CEO) was only present in the hospital 1 day each week, with responsibility of Chief Administrative Officer (CAO) at another out-of-state hospital within the corporation where he worked 4 days each week.


The Conditions of Participation for Patient Rights, QAPI, and Nursing Services were not met.
In addition, Immediate Jeopardy was identified under Patient Rights with additonal concerns regarding patient safety.

Please reference A57, A115, A144, A175, A 178, A263, A273, A283, A286, A309, A385, A386, A392, A395, A396, and A405.

Based on clinical record reviews (Patients #6, 10, 27), review of hospital documentation, meeting minutes, and interviews, the hospital's governing body failed to ensure that the Chief Executive Officer was responsible for the management of the hospital when the hospital's Chief Administrative Officer (position of CEO) was only present in the hospital 1 day each week, with responsibility of Chief Administrative Officer (CAO) at another out-of-state hospital within the corporation where he worked 4 days each week. The findings include:

Review of the hospital's organizational chart identified that the CAO was responsible for all services in the hospital. Review of a document provided by the CAO identified that he dedicated 25% of his time (Fridays) at the hospital. The document also identified that the Chief Nursing Officer (CNO) was only at the hospital 40% of the time (Tuesdays & Fridays).

Interview with the CAO on 4/12/23 at 12:20 PM identified that he was effective in the position of CAO because he ensured that there was a Director presence at the hospital where there was none before.

Interview with the CNO on 4/13/23 at 9:30 AM identified that she was effective in the CNO role because she has Department Directors on-site.

Review of the document provided by the CAO identified that Department Directors were only present in the hospital 40% of the time, and spent the remainder of their time at another out-of-state hospital within the corporation where they worked 60% of their time each week.

Interview with the Chairman of the Governing Body on 4/13/23 at 9:00 AM identified that the Governing Body was responsible for overseeing the quality in the hospital and that the board has been apprised of hospital vulnerabilities, but the Chairman was not made aware of an incident with Patient #6 harming self in the Emergency Department (ED) (identified below). The Chairman identified that the board was aware of staffing problems and that "you can't have safety without staff". Also, the Chairman was not aware of any quality assessment and performance improvement projects initiated in the setting of decreased staffing.

Review of adverse events at the hospital identified two incidents of patient self-harm in the ED where patients with behavioral health needs were placed in the main ED instead of the psychiatrically safe ED behavioral health unit and one incident of self-harm on the in-patient behavioral health unit, and one incident of elopement in the main ED.

a. On 3/21/23 at 12:33 AM, Patient #6 was ordered to be on constant monitoring for suicidal ideation, but the sitter was also conducting constant monitoring on another patient. Patient #6 told the sitter "I'm leaving", ran to the bathroom and locked the door. The sitter notified RN #15 who went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering. Security was notified, the RN broke open the locked door, and found Patient #6 lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for". The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), failed to remediate the lockable door in a timely manner, and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time. Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

b. On 4/10/23 Patient #10 was admitted to the ED with suicidal ideation and an ED Tech allowed the patient to be in the bathroom unescorted and prior to the patient changing to hospital clothes and being searched for contraband items. While in the bathroom the patient cut his/her wrist with a razor. A note by RN #2 dated 4/10/23 at 11:13 AM identified that she noticed the ED Tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the Tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist. A crisis assessment date 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures.

This incident resulted in a finding of Immediate Jeopardy.

c. On 4/13/23 at 12:45 AM Patient #10 was on the in-patient behavioral health unit and was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips. The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for, enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.
Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

d. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier. An interview with Emergency Department Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patients #25 and #27 on the day Patient #27 eloped. ED Technician #4 identified Patient #27 walked out of sight of the sitter and indicated the sitter went after Patient #27. ED Technician #4 stated that at the time she pursued Patient # 27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

Interviews with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit.

The Condition of Participation for Patient Rights has not been met.


Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for 11 of 17 patients reviewed for care in a safe setting (Patients #5, 6, 8,9, 10, 11, 12, 20, 25, 27, 33), the hospital failed to ensure that a safe environment was provided that protected the patient's physical and emotional health, resulting in a finding of Immediate Jeopardy.

Subsequently, the hospital reviewed and revised the policy entitled, Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.



Please see A144, A175, A178


A144:
Following this incident, the hospital reviewed and revised the policy entitled, Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.

The hospital failed to ensure that the patient received adequate supervision in the Emergency Department (ED) when the patient was left unattended in the bathroom and slit their wrist with a razor (Patient #10);

failed to perform constant monitoring of patients on suicide precautions who then locked self in the ED bathroom and placed a bag over their head (Patient #6), eloped (Patient #25), and who required constant supervision (Patients 27 and 33);

failed to ensure that sharps including dining utensils were accounted for on the in-patient behavioral health unit and the patient cut open the sutures in a wrist wound with a dining utensil (Patient #10);

failed to ensure that a patient was free from medical error when the intended mass was not surgically removed resulting in a delay in treatment (Patient #5);

failed to ensure that a patient was not burned during warm soak treatments (Patient #8);

failed to ensure that nursing staff responded to an emergency code consistent with the hospital's policy (Patient #20);

failed to ensure that patients identified as a fall risk (Patients #9, 11, 49) were afforded precautionary measures of fall alert wrist bands, fall alert socks, and fall alert signage; and

failed to ensure that patients were identifiable when they were observed without identification bracelets and had no alternate plan if the patient refused (Patients 9, 12).



A 175:
Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for one of three sampled patients (Patient #24) who were reviewed for restraints, the hospital failed to ensure that the patient was assessed for injury after the restraints were discontinued per the hospital's practice.



A 178:
Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for one of three sampled patients (Patient #23) who were reviewed for restraints, the hospital failed to ensure there was documentation that a face-to-face physician/ licensed independent practitioner assessment was conducted per policy.

Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for 11 of 17 patients reviewed for care in a safe setting (Patients #5, 6, 8,9, 10, 11, 12, 20, 25, 27, 33), the hospital failed to ensure that a safe environment was provided that protected the patient's physical and emotional health, resulting in a finding of Immediate Jeopardy.

Subsequently, the hospital reviewed and revised the policy entitled, Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.

The hospital failed to ensure that the patient received adequate supervision in the Emergency Department (ED) when the patient was left unattended in the bathroom and slit their wrist with a razor (Patient #10);

failed to perform constant monitoring of patients on suicide precautions who then locked self in the ED bathroom and placed a bag over their head (Patient #6), eloped (Patient #25), and who required constant supervision (Patients 27 and 33);

failed to ensure that sharps including dining utensils were accounted for on the in-patient behavioral health unit and the patient cut open the sutures in a wrist wound with a dining utensil (Patient #10);

failed to ensure that a patient was free from medical error when the intended mass was not surgically removed resulting in a delay in treatment (Patient #5);

failed to ensure that a patient was not burned during warm soak treatments (Patient #8);

failed to ensure that nursing staff responded to an emergency code consistent with the hospital's policy (Patient #20);

failed to ensure that patients identified as a fall risk were afforded precautionary measures of fall alert wrist bands, fall alert socks, and fall alert signage (Patients #9, 11, 49); and

failed to ensure that patients were identifiable when they were observed without identification bracelets and had no alternate plan if the patient refused (Patients 9, 12).

The findings include:



a. Patient #10 was admitted to the Emergency Department (ED) on 4/10/23 at 10:12 AM with a documented complaint of "mental status" and placed in a main ED room at 10:16 AM. ED Tech #1 documented that vital signs were obtained and at 10:21 AM a physician was assigned and ordered laboratory blood work, urinalysis, and a consultation for a crisis evaluation. There was no order for safety monitoring. At 10:54 AM a nurse was assigned and identified a chief complaint of "suicidal", acuity level of 2, and documented that the patient walked into the ED, unsure what was said to admission staff, patient brought back, and the assigned tech brought the patient to the bathroom. A note by RN #2 dated 4/10/23 at 11:13 AM identified that it was reported to her that the patient walked into the ED with a complaint of suicidal ideation, was brought back to a room, and she noticed the tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist, the patient was brought back to the room, and one-to-one observation began. RN #2 did not identify the patient's injury. A crisis assessment dated 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures. The patient was admitted to the inpatient psychiatric unit.

On 4/10 /23 at 10:34 AM this writer observed Patient #10 being wheeled from the bathroom back to the bedroom. Observation of the bathroom identified 2 small razor type pieces of metal on the sink with frank blood in the sink, on the floor below the sink, on the floor by the wall where the patient had sat, and on the door handle.

Interview with ED Tech #2 on 4/10/23 at 1:50 PM identified that Patient #10 came in with self-harming thoughts, he gathered hospital clothing and a urine cup, and walked the patient down the hall to a bathroom to change and provide the urine sample. ED Tech #2 stayed outside. Then he could hear water running for "too long", went in, found the patient on the floor, yelled for help, and put pressure on the wound. ED Tech #2 stated that he should have asked another staff member to go into the bathroom with the patient.

Interview with MD #3 on 4/12/23 at 1:45 PM identified that she had not seen the patient yet as the patient had been in the triage period, and she was working in the express area of the ED at the time. MD #3 identified that Patient #10 should not have been left alone in the bathroom.

Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

Interview with RN #2 on 4/17/23 at 9:00 AM identified that she was with a provider receiving report on 2 other patients when she saw Patient #10 and ED Tech #2 in the room and then walk towards the bathroom. A few minutes later she did not see the patient in the room, went down the hall towards the bathroom, and heard ED Tech yell to call an arrest. The ED Tech told her that he had left the patient alone in the bathroom. RN #2 identified that she had not even spoken to the patient prior to this incident. The patient was assigned to her, but she did not receive a report yet and she should have, since the patient required monitoring.

Interview with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit.

The hospital policy for suicide prevention identified that all ED patients will have a suicide risk screening assessment and patients who score as a high risk or if the RN had concerns will be placed on continuous observation.
The hospital policy Entitled Triage Policy and Procedure in effect on 4/10/23 did not identify the safety monitoring of patients during the triage process. Following this incident, the policy was updated to include that staff would remain with the patient and must be within arm's length of the patient, including in the bathroom.

The hospital failed to ensure that Patient #10 was cared for in a safe setting when the patient was placed in the main ED where there were no policies or procedures on the care of a patient with behavioral health needs instead of utilizing the psychiatrically safe behavioral health unit, there was no nurse-to-nurse hand off of the patient between triage and the main ED, the patient was not provided a timely suicide risk screen, was not searched for contraband items, was not changed into hospital safe clothing prior to being unsupervised, and was allowed unsupervised in the bathroom prior to a contraband search, and cut self with a razor, resulting in a finding of Immediate Jeopardy.

Following this incident of cutting the hospital reviewed and revised the policy entitled Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.


b. Patient #6 was admitted to the Emergency Department (ED) on 3/20/23 with suicidal ideations and placed on a stretcher in the hallway of the main ED. A psychosocial evaluation at 11:52 PM identified the patient had a recent arrest and felt hopeless and isolated, and a sitter was at the bedside. Constant monitoring was ordered at 11:54 PM. Observation monitoring was documented at 12:19 AM and 12:30 PM by Medical Assistant (MA) #1. A note by RN #15 on 3/21/23 at 12:33 AM identified that Patient #6 told the sitter "I'm leaving", ran to the bathroom and locked the door. The sitter notified RN #15 who went to the bathroom, the RN went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering, security was notified, and the RN broke open the locked door. Patient #6 was found lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for".

Interview with RN #15 on 4/12/23 at 8:35 AM identified that the behavior health unit in the ED was closed so Patient #6 was placed in the hallway so the sitter could watch this patient and 2 others. The patient told the sitter she was leaving and ran to the bathroom. RN #15 identified that the bathroom door was locked, she knocked on the door, the patient stated she had nothing to live for, then she could hear the sound of plastic, asked the patient to open the door, but the patient did not respond. RN #15 asked to get security, and by messing with the door handle and pushing on the door, it popped open. Patient #6 was found lying on the floor with a bag over the head, and she took the bag off. The patient never lost consciousness. RN #15 stated that since this incident, there are no more plastic bags in the hallway or bathroom and that it was made clear not to leave patients alone in the bathroom.

Interview with MA #1 on 4/13/23 at 10:35 AM identified that on 3/21/23 she was doing constant monitoring on 2 patients and watching a third (later identified as Patients #33 and #38). Patient #6 was on a stretcher in the hall, was trying to get the side rails down, said he/she had to go, then got up and ran to the bathroom. MA #1 notified the nurse and stayed with the other 2 patients. MA #1 stated she did not have training on how many patients she could watch at the same time.

Patient #33 was admitted to the ED on 3/20/23 with suicidal ideation, placed in a room in the main ED, and was placed on suicide precautions - constant observation by the Physician Assistant. Constant observations were documented on 3/21/23 at 12:00 AM and 12:15 PM and "continued" at 12:30 PM, which were the same timeframe that Patient #6 was being observed.

Interviews with the Chief Nursing Officer (CNO), Director of the ED and Behavioral Health, and the RN assigned to assist with staff education on 4/12/23 at 2:45 PM identified that the hospital did not have a policy specific for levels of observation and staff responsibilities for each level. The CNO stated that if a patient is suicidal, they should be on a one-to-one and the sitter should not be watching other patients, and the other patient being observed by MA #1 on 3/21/23 was Patient #33.

Review of hospital documentation identified that as a result of this incident, plastic bags were removed from the bathroom, however, the hospital failed to address the locking mechanism of the door of the bathroom designated for behavioral patients in the main ED. Subsequent to surveyor inquiry, the locking mechanism was removed from the door on 4/11/23.

The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time and failed to ensure that Patient #33 was afforded a constant observer within arm's length at all times.

The hospital policy for behavioral health - patient observation and safety identified plastic bags as a dangerous item and to ensure that it is removed from the patient's immediate environment.
The hospital policy for suicide precautions identified that the patient on constant observation will be assigned a constant observer who will be within arm's length at all times and will not engage in any other activity. The policy failed to identify the number of patients that can be observed by a single observer.


c. Patient #27 was admitted to the Emergency department with diagnoses to include depression and anxiety and making suicidal ideation statements.

The ED provider note dated 3/7/23 at 3:28 PM identified Patient #27 became combative wishing to leave and identified that the patient was not safe to be discharged without being cleared by crisis. The note identified that Patient #27 was placed on physician emergency certificate (PEC) and identified patient appeared to pose harm to self and others.

An ED RN note dated 3/7/23 at 5:11 PM identified that Patient #27 was increasingly anxious, requesting to leave, and was placed on PEC with a sitter at the bedside.

A physician's order dated 3/7/23 at 11:23 PM directed suicide precautions - includes continuous observations with patient safety attendant for risk of injury to self or others.

The history and physical note dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier.

Patient #25 presented to the Emergency department (ED) with diagnoses of depression and suicidal ideation.

The ED provider note dated 3/7/23 identified Patient #25 presented with history of worsening depression and identified that the patient stated s/he was feeling very hopeless and had no reason to live. The note identified patient would be monitored overnight and evaluated by crisis the next morning for worsening thoughts of suicide with no plan.

A physician's order dated 3/7/23 directed suicide precautions including continuous observation with patient safety attendant.

An interview who ED Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patient #25 and #27 on the day that Patient #27 eloped. ED Technician #4 identified that Patient #27 walked out of sight and she went after Patient #27. ED Technician #4 stated that at the time she pursued Patient #27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

Interview with Manager #1 (ED) on 4/11/23 at 12:39 PM identified that continuous observation meant staff was able to always visualize the patient. Manager #1 indicated that Technician #4 should not have left other patients on continuous observation unattended and gone after the eloping patient.

An interview with the Staff Educator on 4/12/23 at 3:00 PM identified when physician's order directs constant observation for a patient who is suicidal, the patient should be on 1:1 observation and the attendant should not be watching other patients at the same time.

Review of the Patient Observation and Safety policy directed the purpose of the policy was to provide an environment that assures the safety of patients and personnel through a systematic plan of patient observation. The policy directed that nursing staff would observe each patient as per the provider order either every 5-minutes, 15-minutes, or constant observation.

The Hospital's policy did not address the use of 1:1 sitter for patients triaged with suicidal ideation.


d. Patient #10 was admitted to the in-patient behavioral health unit on 4/10/23 following an interrupted suicide attempt in the ED and was placed on constant observations. On 4/12/23 the constant observations were discontinued, and the patient was placed on every 5-minute observations. On 4/13/23 at 12:40 AM the patient was noted as responsive in the bathroom and at 12:45 PM was silent (still in the bathroom). Patient #1 was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was placed back on constant observations. On 4/13/23 the patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips.

Interview with the Director of Behavioral Health and the Behavioral Health Manager on 4/17/23 at 12:00 PM identified that historically the behavioral health patients were issued plastic sporks on their meal trays and the unit did not account for the sporks once meals were consumed. It was not known when Patient #10 kept the spork. Following this incident, the sporks are now being accounted for after the meals are finished.

The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.

Interview with the Director of Behavioral Health on 4/17/23 identified that she would be following up with the staff who did not complete the audits and monitoring.


e. Patient #5 was diagnosed with invasive left breast carcinoma, had two biopsies and clips (markers) were placed at each site at another health care facility. The biopsies identified one benign mass and one mass with invasive carcinoma. On 1/25/21 the patient was admitted to this hospital and MD #5 performed a left partial mastectomy with needle location and left sentinel node biopsy. Results of the biopsy dated 1/27/21 identified no evidence of carcinoma.

Review of hospital documentation dated 11/4/21 identified that during Patient #5's partial mastectomy, there was a failure to recognize the two markers that were placed prior to surgery, the wrong mass was biopsied, and there was a failure to follow up on the benign biopsy results. Also identified was the unavailability of the radiological images from the outside facility.

Interview with MD #5 on 4/12/23 at 9:00 AM and again on 4/18/23 at approximately 9:00 AM identified that the intention was to remove the mass with the carcinoma, but the benign mass was identified and removed in error. MD #5 identified that the radiologist did not have all the radiologic images from the outside facility at the time of the surgery and only identified one clip and that was the mass that was removed. MD #5 identified that she reviewed the pathology report postoperatively.

Interview with Radiologist #1 on 4/24/23 at 9:05 AM (requested prior to survey exit date) identified that on 1/25/21 he only had a radiological image that the technician took the day of surgery and only one clip was seen, and he localized the area for the surgeon using mammography. After this incident, Radiologist #1 identified that he refused to participate in procedures unless all imaging was available. The hospital developed policies and procedures and there have been no further issues.

The hospital's universal protocol policy identified that site identification for interventional radiology procedures will be determined at the time of the study based on intra procedural imaging and collaborative team assessment during the verification process.

The hospital's corrective action plan included establishing protocols for needle localization, verifying all radiological images, and reviewing negative pathology results in cases of preoperative diagnoses of carcinoma.


f. Patient #8 was admitted to the hospital on 11/18/21 three weeks post open-heart surgery and right lower extremity saphenous vein removal. The patient was identified with right lower extremity pain, redness, swelling, induration, and warm wet soaks to the affected region were ordered. On 11/19/21 at 4:43 AM RN #14 identified that warm soaks were applied to the right thigh, the area remained red, warm, edematous, small blister-like areas were forming, and a scab remained. An RN documentation on 11/19/21 at 10:57 AM identified that warm wet compresses to right inner thigh continued, and the MD was made aware of non-blanchable areas of the upper inner thigh and blanchable redness to the mid-inner thigh. On 11/19/21 at 12:48 AM Physician Assistant (PA) #1 identified the patient with a right lower extremity wound infection with cellulitis, the patient developed blister-like areas, and the area remains red where warm soaks were placed. Despite redness and blisters, the PA continued the warm soaks. On 11/19/21 at 5:19 PM the MD identified significant blistering of the inner thigh and requested a wound consultation. On 11/19/21 at 7:09 PM a wound care consult by APRN #1 identified the right upper thigh with several blisters and bullae from apparent burns secondary to warm compresses, and that the blisters would need to be debrided. The APRN discontinued the warm soaks.

Review of hospital documentation identified that the hospital supply of heat packs was exhausted, and staff resorted to microwaved washcloths to maintain warm wet compresses.

Interview with RN #14 on 4/17/23 at 3:30 PM identified that when heat packs were no longer available staff warmed up towels and put them on the patient's leg. RN #14 identified that she thought she saw a blister but did not stop the warm soaks because there was a doctor's order for it. RN #14 did not recall id she notified the physician when blisters were noted.

Interview with the CNO on 4/18/23 at 2:00 PM identified that the hospital did not have a policy on warm wet soaks. When warm packs were not available, staff improvised and should not have.

Interview with RN #16 on 4/18/23 at 3:00 PM identified that staff ran out of temperature safe heat packs and had to heat water in the microwave and use washcloths for warm soaks. RN #16 did not recall notifying the MD when heat packs were no longer available.

Interview with APRN #1 on 4/18/23 at 10:15 AM identified that blisters can be a burn and staff should not have applied anything on a burn.


g. Patient #20 was admitted to the hospital with a history of asthma, atrial fibrillation, concerns for sepsis, and presented with a history of altered mental status and fall at home.

The operative note date 3/6/23 identified Patient #20 had significant respiratory failure, developed right pneumothorax, and was in need of an emergent chest tube insertion for chest decompression. The operative note identified the chest tube was inserted with audible gush of air from the chest. The note identified the chest tube was secured and connected to pleur-evac and immediately after, the patient became bradycardic, and a code blue was called. The operative note identified Cardiopulmonary Resuscitation (CPR) was initiated with endotracheal intubation and after a few rounds of CPR, the patient was resuscitated and remained intubated.

A plan of care physician's note dated 3/7/23 identified Patient #20's medical condition was discussed with the patient's next of kin and included worsening renal failure, sepsis and cardiac arrest, and the decision was made to honor the patient's living will and make the patient comfort measure only care (CMO).

An interview with RN #7 on 4/10/23 at 3:00 PM identified that on the day Patient #20 experienced a code blue she was working with only a monitor technician in the ICU. RN #7 identified that she called a code X 2 as emergency department staff did not respond to the code. RN #7 indicated she had to wait to be relieved from chest compressions to retrieve the emergency cart. RN #7 identified there was no nursing supervisor on duty, identified there was an assistant nurse manager on but was not Advanced Cardiovascular Life Support (ACLS) certified, and was unable to assist with code medication administration. RN #7 identified that on days when the hospital is not staffed with a nursing supervisor there is no support. RN #7 stated that when working in the intensive care unit with only one nurse, something could go terribly wrong.

An interview with MD #1 (ED) on 4/11/23 at 1:00 PM identified that when a code was called the practice was for ED staff to respond immediately to assist with medication administration.

An interview with Manager #1 (ED) on 4/11/23 at 2:00 PM identified that on the day of the incident the ED was staffed with 4 RN's but identified there were 21 patients which included 2 intensive care (ICU) level patients in the ED awaiting beds or transfer to another hospital. Manager #1 identified the practice was to have a nursing supervisor (when available) or an emergency room staff respond to a code.

Review of the Nursing administrative supervisor coverage procedure document outlined the Unit manager's responsibilities to include assigning staff from the Emergency Department and the intensive care unit to cover codes on all shifts.


h. Observation on the in-patient geri-psych behavioral health unit with the Program Director on 4/10/23 at 9:00 AM identified that Patient #9 was identified as a fall risk but did not have a fall risk wrist band on, and there was no care plan for an alternative if the patient refused to wear it.

Observation on the in-patient adult behavioral health unit with the Program Director on 4/18/123 at 9:30 AM identified that Patient #11 was identified as a fall risk but did not have a fall risk wrist band on and the bedroom door did not have a fall risk star.

Observation on the in-patient medical/surgical unit with The Assistant Manager and the Director of Emergency Services on 4/18/123 at 11:30 AM identified that Patient #49 was a fall risk but did not have a fall risk wrist band on.

The hospital's fall prevention policy identified in part that yellow bracelets, socks, and door magnets will be implemented for patients identified as a fall risk.


i. Observation on the in-patient geri-psych behavioral health unit with the Program Director on 4/10/23 at 9:00 AM identified that Patient #9 did not have a patient identification bracelet on, and there was no care plan for an alternative if the patient refused to wear it.

Observation on the in-patient adult behavioral health unit with the Program Director on 4/10/23 at 9:00 AM identified that Patient #12 did not have a patient identification bracelet on, and there was no care plan for an alternative if the patient refused to wear it.

Interview with the Program Director on 4/10/23 at 9:30 AM identified that it was hospital policy for all patients to have an identification bracelet on or a care plan for an alternative if the patient refused to wear it. Patients #9 and #12 did not have care plans for refusal of patient identification bracelets.

Based on clinical record reviews, review of hospital documentation, observation, and interviews for one of three sampled patients (Patient #24) who was reviewed for restraints, the hospital failed to ensure that the patient was assessed for injury after the restraints were discontinued per the hospital's practice. The finding includes:

a. Patient #24 presented to the hospital with history of dementia and fall. The clinical record identified that Patient #24 was agitated and attempting to remove an intravenous line.

The physician's order dated 3/11/23 at 6:49 PM directed, Restraints: non-violent or non-self-destructive soft wrist for agitation.

Review of the clinical record with Manager #1 on 4/12/23 at 8:35 AM identified the records lacked documentation an assessment was performed to determine any injury that may have occurred from the restraints.

An interview with Manager #1 on 4/12/23 at 8:45 AM identified it was the expectation that staff should assess and document the patient's skin color, movement, and sensation every 15-minutes while on restraints and document whether there are injuries to the patient at the time restraints are discontinued.

Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for one of three sampled patients (Patient #23) who was reviewed for restraints, the hospital failed to ensure there was documentation that a face-to-face physician/ licensed independent practitioner assessment was conducted per policy. The finding includes:

a. Patient #23's presented to the hospital with history of agitation and schizophrenia.

A physician's order dated 3/20/23 at 10:23 PM directed, Restraints: violent or self-destructive double secured locked wrist/ankle continuous x 4 hours.

Review of the clinical records with Manager #1 on 4/12/23 at 8:30 AM identified 4- point restraints were initiated at 10:25 PM on 3/10/23 and discontinued at 11:22 PM.

The clinical record lacked documentation a physician's face to face assessment was completed.

An interview with Manager #1 on 4/12/23 at 8:45 AM identified it was the expectation that the medical staff performed and documented a face-to-face assessment of all patients placed on restraints.

Review of the Restraint policy directed a face-to-face Physician/ licensed independent practitioner must be conducted to evaluate the patient within an hour after the initiation of restraints and document the patient's behavior and assessment necessitating the use of restraints.

The Condition of Participation of QAPI has not been met.

A273:
Based on review of clinical records, hospital documentation, meeting minutes, and interviews for 3 of 6 patients reviewed for adverse events (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program collected and analyzed data on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, failed to account for sharps on the in-patient behavioral health unit, and failed to ensure that the QAPI program addressed these serious safety/adverse events.


A283:
Based on clinical record reviews, review of hospital documentation, meeting minutes, and interviews, for 3 of 6 patients reviewed for safety (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program identified opportunities for improvement on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, failed to identify that the in-patient behavioral health unit had sharps in the milieu, and failed to identify opportunities following multiple serious safety events.



A286:
Based on clinical record reviews, review of hospital documentation, meeting minutes, and interviews, for 3 of 3 patients (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program analyzed adverse events and implemented QAPI initiatives following multiple serious safety/adverse events.



A309:
Based on review of hospital documentation, meeting minutes, and interviews, the hospital's Governing Body failed to ensure that the Chief Executive Officer was responsible for the management of the hospital when the hospital's Chief Administrative Officer (position of CEO) was only present in the hospital 1 day each week, with responsibility of CAO at another out-of-state hospital within the corporation where he worked 4 days each week.


Please see A273, A283, A286, A309

Based on review of clinical records, hospital documentation, meeting minutes, and interviews for 3 of 6 reviewed for adverse events (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program collected and analyzed data on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, failed to account for sharps on the in-patient behavioral health unit, and failed to ensure that the QAPI program addressed these serious safety/adverse events. The findings include:

Review of adverse events at the hospital identified two incidents of patient self-harm in the ED where patients with behavioral health needs were placed in the main ED instead of the psychiatrically safe ED behavioral health unit, one incident of self-harm on the in-patient behavioral health unit, and one incident of elopement from the main ED.

a. On 3/21/23 at 12:33 AM, Patient #6 was in the main ED and ordered to be on constant monitoring for suicidal ideation, but the sitter was also conducting constant monitoring on another patient. Patient #6 told the sitter "I'm leaving", ran to the bathroom unescorted and locked the door. The sitter notified RN #15 who went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering. Security was notified, the RN broke open the locked door, and found Patient #6 lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for". The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), failed to remediate the lockable door in a timely manner, and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time.

b. On 4/10/23 Patient #10 was admitted to the ED with suicidal ideation and an ED Tech allowed the patient to be in the bathroom unescorted and prior to the patient changing to hospital clothes and being searched for contraband items. While in the bathroom the patient cut his/her wrist with a razor. A note by RN #2 dated 4/10/23 at 11:13 AM identified that she noticed the ED Tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the Tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist. A crisis assessment date 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures. This incident resulted in a finding of Immediate Jeopardy.

c. On 4/13/23 at 12:45 AM Patient #10 was on the in-patient behavioral health unit and was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips. The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for, enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.

d. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier. An interview with Emergency Department Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patients #25 and #27 on the day Patient #27 eloped. ED Technician #4 identified Patient #27 walked out of sight of the sitter and indicated the sitter went after Patient #27. ED Technician #4 stated that at the time she pursued Patient # 27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

The hospital's QAPI plan identified a purpose to delineate structures and functions to improve systems and processes to ensure safe and effective patient care.

Interview with the Chairman of the Governing Body on 4/13/23 at 9:00 AM identified that the Governing Body was responsible for overseeing the quality in the hospital. and that the board has been apprised of hospital vulnerabilities, but the Chairman was not made aware of an incident with Patient #6 harming self in the Emergency Department (ED) (identified below). The Chairman identified that the board was aware of staffing problems but was not aware of any QAPI projects initiated in the setting of decreased staffing.

Interviews with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing.

The Hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program collected and analyzed data on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, and failed to ensure that the QAPI program addressed these serious safety events.

Based on clinical record reviews, review of hospital documentation, meeting minutes, and interviews, for 3 of 6 patients reviewed for safety (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program identified opportunities for improvement on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, failed to identify that the in-patient behavioral health unit had sharps in the milieu, and failed to identify opportunities following multiple serious safety events. The findings include:

a. On 3/21/23 Patient #6 was in the main ED, ordered to be on constant monitoring due to suicidal ideation, and one technician was observing Patient #6 and one other patient, contrary to a policy that identified that a constant observer would be within arm's length of the patient being monitored. Patient #6 ran to the bathroom unescorted, locked self in the bathroom and placed a bag over their head. The RN responded and had to break open the door to reach the patient and remove the bag from the patient's head.

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

b. On 4/10/23 Patient #10 was in the process of being admitted to the ED with suicidal ideation. The patient was allowed to use the bathroom unattended, still in street clothes and before a contraband search was done. While in the bathroom the patient used a razor blade to cut their wrist, which required suturing. A crisis assessment dated 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom".

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

c. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier. The ED Technician identified that she was sitting for 3 patients, including Patients #25 and #27 on the day that Patient #27 eloped. When Patient #27 walked out of sight of the sitter the sitter went after Patient #27 and was unable to observe the other patients she was assigned to observe. The technician identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time, and she could not do the best job keeping her eyes on 4 patients at once.

Interview with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing.

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

Based on clinical record reviews, review of hospital documentation, meeting minutes, and interviews, for 3 of 6 patients reviewed for safety (Patients #6, #10, and #27), the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program identified opportunities for improvement on the care and safety of the high-risk population of behavioral health patients being cared for in the main Emergency Department (ED) when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues, failed to identify that the in-patient behavioral health unit had sharps in the milieu, and failed to identify opportunities following multiple serious safety events. The findings include:

a. On 3/21/23 Patient #6 was in the main ED, ordered to be on constant monitoring due to suicidal ideation, and one technician was observing Patient #6 and one other patient, contrary to a policy that identified that a constant observer would be within arm's length of the patient being monitored. Patient #6 ran to the bathroom unescorted, locked self in the bathroom and placed a bag over their head. The RN responded and had to break open the door to reach the patient and remove the bag from the patient's head.

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

b. On 4/10/23 Patient #10 was in the process of being admitted to the ED with suicidal ideation. The patient was allowed to use the bathroom unattended, still in street clothes and before a contraband search was done. While in the bathroom the patient used a razor blade to cut their wrist, which required suturing. A crisis assessment dated 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom".

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

c. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier. The ED Technician identified that she was sitting for 3 patients, including Patients #25 and #27 on the day that Patient #27 eloped. When Patient #27 walked out of sight of the sitter the sitter went after Patient #27 and was unable to observe the other patients she was assigned to observe. The technician identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time, and she could not do the best job keeping her eyes on 4 patients at once.

Interview with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing.

Review of QAPI documentation and interview with the Director of QAPI on 4/17/23 at 3:40 PM and on 4/18/23 at 9:20 AM identified that the hospital did not initiate any QAPI initiatives to ensure the safety of behavioral health patients being care for in the main ED following this event.

Based on review of hospital documentation, meeting minutes, and interviews, the hospital's Governing Body failed to ensure that the Chief Executive Officer was responsible for the management of the hospital when the hospital's Chief Administrative Officer (position of CEO) was only present in the hospital 1 day each week, with responsibility of CAO at another out-of-state hospital within the corporation where he worked 4 days each week. As a result, gaps in communication regarding serious events and failure to ensure QAPI projects were initiated to prevent further incidences of patient harm and Immediate Jeopardy was identified. The findings include:

Review of the hospital's organizational chart identified that the CAO was responsible for all services in the hospital. Review of a document provided by the CAO identified that he dedicated 25% of his time (Fridays) at the hospital. The document also identified that the Chief Nursing Officer (CNO) was only at the hospital 40% of the time (Tuesdays & Fridays).

Interview with the CAO on 4/12/23 at 12:20 PM identified that he was effective in the position of CAO because he ensured that there was a Director presence at the hospital where there was none before.

Interview with the CNO on 4/13/23 at 9:30 AM identified that she was effective in the CNO role because she has Department Directors on-site.

Review of the document provided by the CAO identified that Department Directors were only present in the hospital 40% of the time and spent the remainder of their time at another out-of-state hospital within the corporation where they worked 60% of their time each week.

Interview with the Chairman of the Governing Body on 4/13/23 at 9:00 AM identified that the Governing Body was responsible for overseeing the quality in the hospital and that the board has been apprised of hospital vulnerabilities, but the Chairman was not made aware of an incident with Patient #6 harming self in the Emergency Department (ED) (identified below). The Chairman identified that the board was aware of staffing problems and that "you can't have safety without staff". Also, the Chairman was not aware of any quality assessment and performance improvement projects initiated in the setting of decreased staffing.

Review of adverse events at the hospital identified two incidents of patient self-harm in the ED where patients with behavioral health needs were placed in the main ED instead of the psychiatrically safe ED behavioral health unit, one incident of self-harm on the in-patient behavioral health unit, and one incident of elopement from the main ED.

a. On 3/21/23 at 12:33 AM, Patient #6 was ordered to be on constant monitoring for suicidal ideation, but the sitter was also conducting constant monitoring on another patient. Patient #6 told the sitter "I'm leaving", ran to the bathroom unescorted and locked the door. The sitter notified RN #15 who went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering. Security was notified, the RN broke open the locked door, and found Patient #6 lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for". The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), failed to remediate the lockable door in a timely manner, and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time.

b. On 4/10/23 Patient #10 was admitted to the ED with suicidal ideation and an ED Tech allowed the patient to be in the bathroom unescorted and prior to the patient changing to hospital clothes and being searched for contraband items. While in the bathroom the patient cut his/her wrist with a razor. A note by RN #2 dated 4/10/23 at 11:13 AM identified that she noticed the ED Tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the Tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist. A crisis assessment date 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures.

This incident resulted in a finding of Immediate Jeopardy.

c. On 4/13/23 at 12:45 AM Patient #10 was on the in-patient behavioral health unit and was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips. The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for, enabling a patient to harm self, and failed to ensure that staff were compliant with the hospital's action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.

d. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier. An interview with Emergency Department Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patients #25 and #27 on the day Patient #27 eloped. ED Technician #4 identified Patient #27 walked out of sight of the sitter and indicated the sitter went after Patient #27. ED Technician #4 stated that at the time she pursued Patient # 27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

Interviews with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit.

The Condition of Participation of Nursing Service has not been met.


A386:
Based on review of clinical records, hospital documentation, meeting minutes, and interviews, the hospital failed to ensure a well-organized Nursing Service department when it was identified that the Chief Nursing Officer (CNO) only worked 40% of the time at the hospital with responsibility of CNO at another out-of-state hospital within the corporation 60% of her time.


A392:
Based on review of clinical records, review of hospital documentation, and interviews for 4 of 6 patients reviewed for safety and staff supervision (Patients #6, 10, 27, & 33) the hospital failed to ensure that behavioral health patients were cared for in a safe environment with appropriate numbers of staff to prevent adverse patient outcomes when staff failed to perform constant monitoring of a patient on suicide precautions who then locked self in the ED bathroom and placed a bag over their head (Patient #6), slit their wrist (Patient #10), eloped (Patient #25), who required constant supervision (Patients #27 and 33), and failed to ensure the availability of nursing leadership, and failed to ensure adequate staffing was scheduled to respond in the event of medical code (Patient #20).


A395:
Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for 7 of 11 patients reviewed for RN supervision of care (Patients #6, 8, 10, 20, 25, 27, 33), the hospital failed to ensure that a patient on suicide precautions received adequate supervision to prevent locking self in the Emergency Department (ED) bathroom and placed a bag over their head (Patient #6, #33), prevent a patient from being unsupervised in the bathroom and slit their wrist with a razor (Patient #10), prevent elopement (Patient #25, 27), prevent a burn from warm soaks (Patient #8), and failed to ensure that nursing staff responded to an emergency code consistent with the hospital's policy (Patient #20).


A396:
Based on clinical record reviews, observation, and interviews for 2 of 6 patients reviewed for identification (Patients #9, 12), the hospital failed to ensure that patients were identifiable when they were observed without wearing identification bracelets.


A405:
Based on clinical record reviews, review of hospital documentation, and interviews for three of three sampled patients (Patient #42, #43, # 44) who were reviewed for medication administration, the hospital failed to ensure staff administered and documented medications consistent with the hospital's policy and practice.


Please see A386, A392, A395, A396, A405

Based on review of clinical records, hospital documentation, meeting minutes, and interviews, the hospital failed to ensure a well-organized Nursing Service department when it was identified that the Chief Nursing Officer (CNO) only worked 40% of the time at the hospital with responsibility of CNO at another out-of-state hospital within the corporation 60% of her time. The findings include:

Review of the hospital's organizational chart identified that the Chief Nursing Officer (CNO) was responsible for the department of nursing.

Review of a document supplied by the CNO and CAO identified that the CNO was only at the hospital 40% of the time (Tuesdays & Fridays).

Interview with the CNO on 4/13/23 at 9:30 AM identified that she was effective in the CNO role because she had Department Directors on-site.

Review of the document provided by the CAO identified that Department Directors for in-patient nursing, emergency department, behavioral health, and perioperative services were only present in the hospital 40% of the time and spent the remainder of their time at another out-of-state hospital within the corporation where they worked 60% of their time each week.

Interview with the Chairman of the Governing Body on 4/13/23 at 9:00 AM identified that the Governing Body was responsible for overseeing the quality in the hospital and that the board has been apprised of hospital vulnerabilities, but the Chairman was not made aware of an incident with Patient #6 harming self in the Emergency Department (ED) (identified below). The Chairman identified that the board was aware of staffing problems and that "you can't have safety without staff", and that he was not aware that the CNO was only at the hospital two days a week.

Review of adverse events at the hospital identified two incidents of patient self-harm in the ED where patients with behavioral health needs were placed in the main ED instead of the psychiatrically safe ED behavioral health unit and one incident of self-harm on the in-patient behavioral health unit.

a. On 3/21/23 at 12:33 AM, Patient #6 was ordered to be on constant monitoring for suicidal ideation, but the sitter was also conducting constant monitoring on another patient. Patient #6 told the sitter "I'm leaving", ran to the bathroom and locked the door. The sitter notified RN #15 who went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering. Security was notified, the RN broke open the locked door, and found Patient #6 lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for". The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), failed to remediate the lockable door in a timely manner, and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time.

b. On 4/10/23 Patient #10 was admitted to the ED with suicidal ideation and an ED Tech allowed the patient to be in the bathroom unescorted and prior to the patient changing to hospital clothes and being searched for contraband items. While in the bathroom the patient cut his/her wrist with a razor. A note by RN #2 dated 4/10/23 at 11:13 AM identified that she noticed the ED Tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the Tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist. A crisis assessment dated 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures.

This incident resulted in a finding of Immediate Jeopardy.

c. On 4/13/23 at 12:45 AM Patient #10 was on the in-patient behavioral health unit and was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips. The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for, enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.
Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

d. On 3/8/23 Patient #27 was in the main ED with suicidal ideation, and ordered to be on constant observation, but the sitter was also conducting constant monitoring on another patient, contrary to hospital policy. The history and physical dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier.

Interviews with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit.

Based on review of clinical records, review of hospital documentation, and interviews for 4 of 6 patients reviewed for safety and staff supervision (Patients #6, 10, 27, & 33) the hospital failed to ensure that behavioral health patients were cared for in a safe environment with appropriate numbers of staff to prevent adverse patient outcomes when staff failed to perform constant monitoring of a patient on suicide precautions who then locked self in the ED bathroom and placed a bag over their head (Patient #6), slit their wrist (Patient #10), eloped (Patient #25), who required constant supervision (Patients #27 and 33), and failed to ensure the availability of nursing leadership, and failed to ensure adequate staffing was scheduled to respond in the event of medical code (Patient #20). The findings include:


Review of the hospital's organizational chart identified that the Chief Nursing Officer (CNO) was responsible for the department of nursing.

Review of a document supplied by the CNO and Chief Administrator (CAO) identified that the CNO was only at the hospital 40% of the time (Tuesdays & Fridays).

Interview with the CNO on 4/13/23 at 9:30 AM identified that she was effective in the CNO role because she had Department Directors on-site.

Review of a document provided by the CAO identified that Department Directors for in-patient nursing, emergency department, behavioral health, and perioperative services were only present in the hospital 40% of the time and spent the remainder of their time at another out-of-state hospital within the corporation where they worked 60% of their time each week.

Review of adverse events at the hospital identified two incidents of patient self-harm in the ED where patients with behavioral health needs were placed in the main ED instead of the psychiatrically safe ED behavioral health unit, one incident of self-harm on the in-patient behavioral health unit, and two patient who did not receive constant monitoring in the ED.


a. On 3/21/23 at 12:33 AM, Patient #6 was ordered to be on constant monitoring for suicidal ideation, but the sitter was also conducting constant monitoring on another patient. Patient #6 told the sitter "I'm leaving", ran to the bathroom and locked the door. The sitter notified RN #15 who went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering. Security was notified, the RN broke open the locked door, and found Patient #6 lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for". The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), failed to remediate the lockable door in a timely manner (still lockable on 4/10/23), and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time.

Patient #33 was admitted to the ED on 3/20/23 with suicidal ideation, placed in a room in the main ED, and was placed on suicide precautions - constant observation by the Physician Assistant. Constant observations were documented on 3/21/23 at 12:00 AM and 12:15 PM and "continued" at 12:30 PM, which were the same timeframe that Patient #6 was being observed.

Interview with RN #15 on 4/12/23 at 8:35 AM identified that the behavior health unit in the ED was closed so Patient #6 was placed in the hallway so the sitter could watch this patient and 2 others. The patient told the sitter she was leaving and ran to the bathroom. RN #15 identified that the bathroom door was locked, she knocked on the door, the patient stated she had nothing to live for, then she could hear the sound of plastic, asked the patient to open the door, but the patient did not respond. RN #15 asked to get security, and by messing with the door handle and pushing on the door, it popped open. Patient #6 was found lying on the floor with a bag over the head, and she took the bag off. The patient never lost consciousness. RN #15 stated that since this incident, there are no more plastic bags in the hallway or bathroom and that it was made clear not to leave patients alone in the bathroom.

Interview with MA #1 on 4/13/23 at 10:35 AM identified that on 3/21/23 she was doing constant monitoring on 2 patients and watching a third (later identified as Patients #33 and #38). Patient #6 was on a stretcher in the hall, was trying to get the side rails down, said he/she had to go, then got up and ran to the bathroom. MA #1 notified the nurse and stayed with the other 2 patients. MA #1 stated she did not have training on how many patients she could watch at the same time.

Interviews with the Chief Nursing Officer (CNO), Director of the ED and Behavioral Health, and the RN assigned to assist with staff education on 4/12/23 at 2:45 PM identified that the hospital did not have a policy specific for levels of observation and staff responsibilities for each level. The CNO stated that if a patient is suicidal, they should be on a one-to-one and the sitter should not be watching other patients, and the other patient being observed by MA #1 on 3/21/23 was Patient #33.

Review of hospital documentation identified that as a result of this incident, plastic bags were removed from the bathroom, however, the hospital failed to address the locking mechanism of the door of the bathroom designated for behavioral patients in the main ED. Subsequent to surveyor inquiry, the locking mechanism was removed from the door on 4/11/23.

The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time and failed to ensure that Patient #33 was afforded a constant observer within arm's length at all times.

The hospital policy for behavioral health - patient observation and safety identified plastic bags as a dangerous item and to ensure that it is removed from the patient's immediate environment.

The hospital policy for suicide precautions identified that the patient on constant observation will be assigned a constant observer who will be within arm's length at all times and will not engage in any other activity. The policy failed to identify the number of patients that can be observed by a single observer.


b. On 4/10/23 Patient #10 was admitted to the ED with suicidal ideation and an ED Tech allowed the patient to be in the bathroom unescorted and prior to the patient changing to hospital clothes and being searched for contraband items. While in the bathroom the patient cut his/her wrist with a razor. A note by RN #2 dated 4/10/23 at 11:13 AM identified that she noticed the ED Tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the Tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist. A crisis assessment date 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures.

Interview with ED Tech #2 on 4/10/23 at 1:50 PM identified that Patient #10 came in with self-harming thoughts, he gathered hospital clothing and a urine cup, and walked the patient down the hall to a bathroom to change and provide the urine sample. ED Tech #2 stayed outside. Then he could hear water running for "too long", went in, found the patient on the floor, yelled for help, and put pressure on the wound. ED Tech #2 stated that he should have asked another staff member to go into the bathroom with the patient.

Interview with MD #3 on 4/12/23 at 1:45 PM identified that she had not seen the patient yet as the patient had been in the triage period, and she was working in the express area of the ED at the time. MD #3 identified that Patient #10 should not have been left alone in the bathroom.

Interview with RN #2 on 4/17/23 at 9:00 AM identified that she was with a provider receiving report on 2 other patients when she saw Patient #10 and ED Tech #2 in the room and then walk towards the bathroom. A few minutes later she did not see the patient in the room, went down the hall towards the bathroom, and heard ED Tech yell to call an arrest. The ED Tech told her that he had left the patient alone in the bathroom. RN #2 identified that she had not even spoken to the patient prior to this incident. The patient was assigned to her, but she did not receive a report yet and she should have, since the patient required monitoring.

Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

Interviews with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit due to staffing issues.

The hospital policy for suicide prevention identified that all ED patients will have a suicide risk screening assessment and patients who score as a high risk or if the RN had concerns will be placed on continuous observation.

The hospital policy Entitled Triage Policy and Procedure in effect on 4/10/23 did not identify the safety monitoring of patients during the triage process. Following this incident, the policy was updated to include that staff would remain with the patient and must be within arm's length of the patient, including in the bathroom.

The hospital failed to ensure that Patient #10 was cared for in a safe setting when the patient was placed in the main ED where there were no policies or procedures on the care of a patient with behavioral health needs instead of utilizing the psychiatrically safe behavioral health unit, there was no nurse-to-nurse hand off of the patient between triage and the main ED, the patient was not provided a timely suicide risk screen, was not searched for contraband items, was not changed into hospital safe clothing prior to being unsupervised, and was allowed unsupervised in the bathroom prior to a contraband search, and cut self with a razor, resulting in a finding of Immediate Jeopardy.

Following this incident of cutting the hospital reviewed and revised the policy entitled Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.
This incident resulted in a finding of Immediate Jeopardy.


c. Patient #10 was admitted to the in-patient behavioral health unit on 4/10/23 following an interrupted suicide attempt in the ED and was placed on constant observations. On 4/12/23 the constant observations were discontinued, and the patient was placed on every 5-minute observations. On 4/13/23 at 12:40 AM the patient was noted as responsive in the bathroom and at 12:45 PM was silent (still in the bathroom). Patient #1 was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was placed back on constant observations. On 4/13/23 the patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips.

Interview with the Director of Behavioral Health and the Behavioral Health Manager on 4/17/23 at 12:00 PM identified that historically the behavioral health patients were issued plastic sporks on their meal trays and the unit did not account for the sporks once meals were consumed. It was not known when Patient #10 kept the spork. Following this incident, the sporks are now being accounted for after the meals are finished.

The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.

Interview with the Director of Behavioral Health on 4/17/23 identified that she would be following up with the staff who did not complete the audits and monitoring.


d. Patient #27 was admitted to the Emergency department with diagnoses to include depression and anxiety and making suicidal ideation statements.

The ED provider note dated 3/7/23 at 3:28 PM identified Patient #27 became combative wishing to leave and identified that the patient was not safe to be discharged without being cleared by crisis. The note identified that Patient #27 was placed on physician emergency certificate (PEC) and identified patient appeared to pose harm to self and others.

An ED RN note dated 3/7/23 at 5:11 PM identified that Patient #27 was increasingly anxious, requesting to leave, and was placed on PEC with a sitter at the bedside.

A physician's order dated 3/7/23 at 11:23 PM directed suicide precautions - includes continuous observations with patient safety attendant for risk of injury to self or others.

The history and physical note dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier.

Patient #25 presented to the Emergency department (ED) with diagnoses of depression and suicidal ideation.

The ED provider note dated 3/7/23 identified Patient #25 presented with history of worsening depression and identified that the patient stated s/he was feeling very hopeless and had no reason to live. The note identified patient would be monitored overnight and evaluated by crisis the next morning for worsening thoughts of suicide with no plan.

A physician's order dated 3/7/23 directed suicide precautions including continuous observation with patient safety attendant.

An interview who ED Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patient #25 and #27 on the day that Patient #27 eloped. ED Technician #4 identified that Patient #27 walked out of sight, and she went after Patient #27. ED Technician #4 stated that at the time she pursued Patient #27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

Interview with Manager #1 (ED) on 4/11/23 at 12:39 PM identified that continuous observation meant staff was able to always visualize the patient. Manager #1 indicated that Technician #4 should not have left other patients on continuous observation unattended and gone after the eloping patient.

An interview with the Staff Educator on 4/12/23 at 3:00 PM identified when physician's order directs constant observation for a patient who is suicidal, the patient should be on 1:1 observation and the attendant should not be watching other patients at the same time.

Review of the Patient Observation and Safety policy directed the purpose of the policy was to provide an environment that assures the safety of patients and personnel through a systematic plan of patient observation. The policy directed that nursing staff would observe each patient as per the provider order either every 5-minutes, 15-minutes, or constant observation.

The Hospital's policy did not address the use of 1:1 sitter for patients triaged with suicidal ideation.


e. Patient #20 was admitted to the hospital with a history of asthma, atrial fibrillation, concerns for sepsis, and presented with a history of altered mental status and fall at home.

The operative note date 3/6/23 identified Patient #20 had significant respiratory failure, developed right pneumothorax, and was in need of an emergent chest tube insertion for chest decompression. The operative note identified the chest tube was inserted with audible gush of air from the chest. The note identified the chest tube was secured and connected to pleur-evac and immediately after, the patient became bradycardic, and a code blue was called. The operative note identified Cardiopulmonary Resuscitation (CPR) was initiated with endotracheal intubation and after a few rounds of CPR, the patient was resuscitated and remained intubated.

A plan of care physician's note dated 3/7/23 identified Patient #20's medical condition was discussed with the patient's next of kin and included worsening renal failure, sepsis and cardiac arrest, and the decision was made to honor the patient's living will and make the patient comfort measure only care (CMO).

An interview with RN #7 on 4/10/23 at 3:00 PM identified that on the day Patient #20 experienced a code blue she was working with only a monitor technician in the ICU. RN #7 identified that she called a code two times as emergency department staff did not respond to the code. RN #7 indicated she had to wait to be relieved from chest compressions to retrieve the emergency cart. RN #7 identified there was no nursing supervisor on duty, identified there was an assistant nurse manager on but was not Advanced Cardiovascular Life Support (ACLS) certified and was unable to assist with code medication administration. RN #7 identified that on days when the hospital is not staffed with a nursing supervisor there is no support. RN #7 stated that when working in the intensive care unit with only one nurse, something could go terribly wrong.

An interview with MD #1 (ED) on 4/11/23 at 1:00 PM identified that when a code was called the practice was for ED staff to respond immediately to assist with medication administration.

An interview with Manager #1 (ED) on 4/11/23 at 2:00 PM identified that on the day of the incident the ED was staffed with 4 RN's but identified there were 21 patients which included 2 intensive care (ICU) level patients in the ED awaiting beds or transfer to another hospital. Manager #1 identified the practice was to have a nursing supervisor (when available) or an emergency room staff respond to a code.

Review of the Nursing administrative supervisor coverage procedure document outlined the Unit Manager's responsibilities to include assigning staff from the Emergency Department and the intensive care unit to cover codes on all shifts.

A Review of the hospital's Nursing supervisors and the Emergency department staffing for dates of 3/1/23 - 4/10/23 identified 6 shifts with no scheduled nursing supervisors and the Emergency room nurse staffing fell below 4 licensed staff.

The hospital failed to ensure adequate staffing was available to respond to medical emergencies (code blue) according to the hospital's practice.

Based on clinical record reviews, review of hospital policies and documentation, observation, and interviews for 7 of 11 patients reviewed for RN supervision of care (Patients #6, 8, 10, 20, 25, 27, 33), the hospital failed to ensure that a patient on suicide precautions received adequate supervision to prevent locking self in the Emergency Department (ED) bathroom and placed a bag over their head (Patient #6, #33), prevent a patient from being unsupervised in the bathroom and slit their wrist with a razor (Patient #10), prevent an eloped (Patient #25, 27), prevent a burn from warm soaks (Patient #8), and failed to ensure that nursing staff responded to an emergency code consistent with the hospital's policy (Patient #20). The findings include:


a. Patient #6 was admitted to the Emergency Department (ED) on 3/20/23 with suicidal ideations and placed on a stretcher in the hallway of the main ED. A psychosocial evaluation at 11:52 PM identified the patient had a recent arrest and felt hopeless and isolated, and a sitter was at the bedside. Constant monitoring was ordered at 11:54 PM. Observation monitoring was documented at 12:19 AM and 12:30 PM by Medical Assistant (MA) #1. A note by RN #15 on 3/21/23 at 12:33 AM identified that Patient #6 told the sitter "I'm leaving", ran to the bathroom and locked the door. The sitter notified RN #15 who went to the bathroom, the RN went to the bathroom and spoke to the patient through the locked door. The patient stated he/she did not want to live any more. The RN heard the sound of a plastic bag, the patient was not answering, security was notified, and the RN broke open the locked door. Patient #6 was found lying on the ground with a plastic bag over the head. The bag was removed, and the patient was crying stating "I don't care, I have nothing to live for".

Interview with RN #15 on 4/12/23 at 8:35 AM identified that the behavior health unit in the ED was closed so Patient #6 was placed in the hallway so the sitter could watch this patient and 2 others. The patient told the sitter she was leaving and ran to the bathroom. RN #15 identified that the bathroom door was locked, she knocked on the door, the patient stated she had nothing to live for, then she could hear the sound of plastic, asked the patient to open the door, but the patient did not respond. RN #15 asked to get security, and by messing with the door handle and pushing on the door, it popped open. Patient #6 was found lying on the floor with a bag over the head, and she took the bag off. The patient never lost consciousness. RN #15 stated that since this incident, there are no more plastic bags in the hallway or bathroom and that it was made clear not to leave patients alone in the bathroom.

Interview with MA #1 on 4/13/23 at 10:35 AM identified that on 3/21/23 she was doing constant monitoring on 2 patients and watching a third (later identified as Patients #33 and #38). Patient #6 was on a stretcher in the hall, was trying to get the side rails down, said he/she had to go, then got up and ran to the bathroom. MA #1 notified the nurse and stayed with the other 2 patients. MA #1 stated she did not have training on how many patients she could watch at the same time.


Patient #33 was admitted to the ED on 3/20/23 with suicidal ideation, placed in a room in the main ED, and was placed on suicide precautions - constant observation by the Physician Assistant. Constant observations were documented on 3/21/23 at 12:00 AM and 12:15 PM and "continued" at 12:30 PM, which were the same timeframe that Patient #6 was being observed.

Interviews with the Chief Nursing Officer (CNO), Director of the ED and Behavioral Health, and the RN assigned to assist with staff education on 4/12/23 at 2:45 PM identified that the hospital did not have a policy specific for levels of observation and staff responsibilities for each level. The CNO stated that if a patient is suicidal, they should be on a one-to-one and the sitter should not be watching other patients, and the other patient being observed by MA #1 on 3/21/23 was Patient #33.

Review of hospital documentation identified that as a result of this incident, plastic bags were removed from the bathroom, however, the hospital failed to address the locking mechanism of the door of the bathroom designated for behavioral patients in the main ED. Subsequent to surveyor inquiry, the locking mechanism was removed from the door on 4/11/23.

The hospital failed to ensure that Patient #6 was care for in a safe setting when the environment was not safe for behavioral health patients (lockable bathroom door and plastic bag in bathroom), and failed to ensure that Patient #6 was constantly observed within arm's length when the observer was tasked with observing one other patient (Patient #33) at the same time and failed to ensure that Patient #33 was afforded a constant observer within arm's length at all times.

The hospital policy for behavioral health - patient observation and safety identified plastic bags as a dangerous item and to ensure that it is removed from the patient's immediate environment.
The hospital policy for suicide precautions identified that the patient on constant observation will be assigned a constant observer who will be within arm's length at all times and will not engage in any other activity. The policy failed to identify the number of patients that can be observed by a single observer.


b. Patient #8 was admitted to the hospital on 11/18/21 three weeks post open-heart surgery and right lower extremity saphenous vein removal. The patient was identified with right lower extremity pain, redness, swelling, induration, and warm wet soaks to the affected region were ordered. On 11/19/21 at 4:43 AM RN #14 identified that warm soaks were applied to the right thigh, the area remained red, warm, edematous, small blister-like areas were forming, and a scab remained. An RN documentation on 11/19/21 at 10:57 AM identified that warm wet compresses to right inner thigh continued, and the MD was made aware of non-blanchable areas of the upper inner thigh and blanchable redness to the mid-inner thigh. On 11/19/21 at 12:48 AM Physician Assistant (PA) #1 identified the patient with a right lower extremity wound infection with cellulitis, the patient developed blister-like areas, and the area remains red where warm soaks were placed. Despite redness and blisters, the PA continued the warm soaks. On 11/19/21 at 5:19 PM the MD identified significant blistering of the inner thigh and requested a wound consultation. On 11/19/21 at 7:09 PM a wound care consult by APRN #1 identified the right upper thigh with several blisters and bullae from apparent burns secondary to warm compresses, and that the blisters would need to be debrided. The APRN discontinued the warm soaks.

Review of hospital documentation identified that the hospital supply of heat packs was exhausted, and staff resorted to microwaved washcloths to maintain warm wet compresses.

Interview with RN #14 on 4/17/23 at 3:30 PM identified that when heat packs were no longer available staff warmed up towels and put them on the patient's leg. RN #14 identified that she thought she saw a blister but did not stop the warm soaks because there was a doctor's order for it. RN #14 did not recall id she notified the physician when blisters were noted.

Interview with the CNO on 4/18/23 at 2:00 PM identified that the hospital did not have a policy on warm wet soaks. When warm packs were not available, staff improvised and should not have.

Interview with RN #16 on 4/18/23 at 3:00 PM identified that staff ran out of temperature safe heat packs and had to heat water in the microwave and use washcloths for warm soaks. RN #16 did not recall notifying the MD when heat packs were no longer available.

Interview with APRN #1 on 4/18/23 at 10:15 AM identified that blisters can be a burn and staff should not have applied anything on a burn.


c. Patient #10 was admitted to the Emergency Department (ED) on 4/10/23 at 10:12 AM with a documented complaint of "mental status" and placed in a main ED room at 10:16 AM. ED Tech #1 documented that vital signs were obtained and at 10:21 AM a physician was assigned and ordered laboratory blood work, urinalysis, and a consultation for a crisis evaluation. There was no order for safety monitoring. At 10:54 AM a nurse was assigned and identified a chief complaint of "suicidal", acuity level of 2, and documented that the patient walked into the ED, unsure what was said to admission staff, patient brought back, and the assigned tech brought the patient to the bathroom. A note by RN #2 dated 4/10/23 at 11:13 AM identified that it was reported to her that the patient walked into the ED with a complaint of suicidal ideation, was brought back to a room, and she noticed the tech walking the patient to the bathroom to change. RN #2 walked towards the bathroom, saw the door opened, and the tech yelled for help. The patient was sitting on the floor against the wall and the tech yelled to call a code. The patient was awake, breathing, a pad was held to the patient's wrist, the patient was brought back to the room, and one-to-one observation began. RN #2 did not identify the patient's injury. A crisis assessment dated 4/10/23 at 2:30 PM identified that on arrival to the ED patient attempted to cut wrist in an interrupted suicide attempt. The patient had planned to kill his/herself by cutting a wrist and stated, "I wish I had a couple more minutes in that bathroom". A physician note dated 4/10/23 at 3:15 PM identified a 2cm superficial laceration over the left wrist which was closed with 3 sutures. The patient was admitted to the inpatient psychiatric unit.

On 4/10 /23 at 10:34 AM this writer observed Patient #10 being wheeled from the bathroom back to the bedroom. Observation of the bathroom identified 2 small razor type pieces of metal on the sink with frank blood in the sink, on the floor below the sink, on the floor by the wall where the patient had sat, and on the door handle.

Interview with ED Tech #2 on 4/10/23 at 1:50 PM identified that Patient #10 came in with self-harming thoughts, he gathered hospital clothing and a urine cup, and walked the patient down the hall to a bathroom to change and provide the urine sample. ED Tech #2 stayed outside. Then he could hear water running for "too long", went in, found the patient on the floor, yelled for help, and put pressure on the wound. ED Tech #2 stated that he should have asked another staff member to go into the bathroom with the patient.

Interview with MD #3 on 4/12/23 at 1:45 PM identified that she had not seen the patient yet as the patient had been in the triage period, and she was working in the express area of the ED at the time. MD #3 identified that Patient #10 should not have been left alone in the bathroom.

Interview with the Director of the ED and Behavioral Health on 4/10/23 at 1:30 PM identified that ED Tech #2 did not secure the patient's clothing and should not have left Patient #10 in the bathroom unattended. The Director identified that the hospital had a behavioral health unit within the ED, which was safe for patients, but it was closed due to a lack of staff. Additionally, the hospital did not have a policy or procedure on how to manage a patient with behavioral health needs in the main ED.

Interview with RN #2 on 4/17/23 at 9:00 AM identified that she was with a provider receiving report on 2 other patients when she saw Patient #10 and ED Tech #2 in the room and then walk towards the bathroom. A few minutes later she did not see the patient in the room, went down the hall towards the bathroom, and heard ED Tech yell to call an arrest. The ED Tech told her that he had left the patient alone in the bathroom. RN #2 identified that she had not even spoken to the patient prior to this incident. The patient was assigned to her, but she did not receive a report yet and she should have, since the patient required monitoring.

Interview with the Chief Administrative Officer (CAO) and Chief Nursing Officer (CNO) on 4/13/23 at 9:30 AM and again at 2:00 PM identified that the behavioral health unit in the ED was closed in 2020 and remained closed due to staffing issues with only occasional use. The CAO and CNO identified that the hospital did not conduct an assessment or process flow of behavioral health patients being cared for in the main ED when the hospital closed the psychiatrically safe ED behavioral health unit.

The hospital policy for suicide prevention identified that all ED patients will have a suicide risk screening assessment and patients who score as a high risk or if the RN had concerns will be placed on continuous observation.
The hospital policy Entitled Triage Policy and Procedure in effect on 4/10/23 did not identify the safety monitoring of patients during the triage process. Following this incident, the policy was updated to include that staff would remain with the patient and must be within arm's length of the patient, including in the bathroom.

The hospital failed to ensure that Patient #10 was cared for in a safe setting when the patient was placed in the main ED where there were no policies or procedures on the care of a patient with behavioral health needs instead of utilizing the psychiatrically safe behavioral health unit, there was no nurse-to-nurse hand off of the patient between triage and the main ED, the patient was not provided a timely suicide risk screen, was not searched for contraband items, was not changed into hospital safe clothing prior to being unsupervised, and was allowed unsupervised in the bathroom prior to a contraband search, and cut self with a razor, resulting in a finding of Immediate Jeopardy.

Following this incident of cutting the hospital reviewed and revised the policy entitled Changing Patients and Search Process-ED, educated staff, and initiated audits. The Immediate Jeopardy was removed/abated on 4/11/23.


d. Patient #10 was admitted to the in-patient behavioral health unit on 4/10/23 following an interrupted suicide attempt in the ED and was placed on constant observations. On 4/12/23 the constant observations were discontinued, and the patient was placed on every 5-minute observations. On 4/13/23 at 12:40 AM the patient was noted as responsive in the bathroom and at 12:45 PM was silent (still in the bathroom). Patient #1 was found sitting in the shower having opened the wrist wound with a spork (half spoon/half fork), and approximately 50 cc of blood was noted. The patient was placed back on constant observations. On 4/13/23 the patient was evaluated by the Physician Assistant who noted the patient had removed the sutures of the left wrist and a 4 cm linear laceration was closed with 5 steri-strips.

Interview with the Director of Behavioral Health and the Behavioral Health Manager on 4/17/23 at 12:00 PM identified that historically the behavioral health patients were issued plastic sporks on their meal trays and the unit did not account for the sporks once meals were consumed. It was not known when Patient #10 kept the spork. Following this incident, the sporks are now being accounted for after the meals are finished.

The hospital failed to ensure a safe environment on the in-patient behavioral health unit when dining utensils (sporks) were not accounted for enabling a patient to harm self, and failed to ensure that staff were compliant with their action plans when review of every 5-minute safety monitoring for Patient #10 on 4/17/23 identified that on 4/12/23, 3 sets of monitoring were not completed or documented at 6:45 PM, 6:50 PM and 6:55 PM. And review of the audits for sporks on the behavioral health unit on 4/17/23 identified that the 4/16/23 11-7 shift did not complete any auditing of the 24 audit items.

Interview with the Director of Behavioral Health on 4/17/23 identified that she would be following up with the staff who did not complete the audits and monitoring.


e. Patient #20 was admitted to the hospital with a history of asthma, atrial fibrillation, concerns for sepsis, and presented with a history of altered mental status and fall at home.

The operative note date 3/6/23 identified Patient #20 had significant respiratory failure, developed right pneumothorax, and was in need of an emergent chest tube insertion for chest decompression. The operative note identified the chest tube was inserted with audible gush of air from the chest. The note identified the chest tube was secured and connected to pleur-evac and immediately after, the patient became bradycardic, and a code blue was called. The operative note identified Cardiopulmonary Resuscitation (CPR) was initiated with endotracheal intubation and after a few rounds of CPR, the patient was resuscitated and remained intubated.

A plan of care physician's note dated 3/7/23 identified Patient #20's medical condition was discussed with the patient's next of kin and included worsening renal failure, sepsis and cardiac arrest, and the decision was made to honor the patient's living will and make the patient comfort measure only care (CMO).

An interview with RN #7 on 4/10/23 at 3:00 PM identified that on the day Patient #20 experienced a code blue she was working with only a monitor technician in the ICU. RN #7 identified that she called a code X 2 as emergency department staff did not respond to the code. RN #7 indicated she had to wait to be relieved from chest compressions to retrieve the emergency cart. RN #7 identified there was no nursing supervisor on duty, identified there was an assistant nurse manager on but was not Advanced Cardiovascular Life Support (ACLS) certified, and was unable to assist with code medication administration. RN #7 identified that on days when the hospital is not staffed with a nursing supervisor there is no support. RN #7 stated that when working in the intensive care unit with only one nurse, something could go terribly wrong.

An interview with MD #1 (ED) on 4/11/23 at 1:00 PM identified that when a code was called the practice was for ED staff to respond immediately to assist with medication administration.

An interview with Manager #1 (ED) on 4/11/23 at 2:00 PM identified that on the day of the incident the ED was staffed with 4 RN's but identified there were 21 patients which included 2 intensive care (ICU) level patients in the ED awaiting beds or transfer to another hospital. Manager #1 identified the practice was to have a nursing supervisor (when available) or an emergency room staff respond to a code.

Review of the Nursing administrative supervisor coverage procedure document outlined the Unit manager's responsibilities to include assigning staff from the Emergency Department and the intensive care unit to cover codes on all shifts.

f. Patient #27 was admitted to the Emergency department with diagnoses to include depression and anxiety and making suicidal ideation statements.

The ED provider note dated 3/7/23 at 3:28 PM identified Patient #27 became combative wishing to leave and identified that the patient was not safe to be discharged without being cleared by crisis. The note identified that Patient #27 was placed on physician emergency certificate (PEC) and identified patient appeared to pose harm to self and others.

An ED RN note dated 3/7/23 at 5:11 PM identified that Patient #27 was increasingly anxious, requesting to leave, and was placed on PEC with a sitter at the bedside.

A physician's order dated 3/7/23 at 11:23 PM directed suicide precautions - includes continuous observations with patient safety attendant for risk of injury to self or others.

The history and physical note dated 3/8/23 identified that Patient #27 eloped from the emergency room, ran into the parking lot, and launched self over the car barrier.

Patient #25 presented to the Emergency department (ED) with diagnoses of depression and suicidal ideation.

The ED provider note dated 3/7/23 identified Patient #25 presented with history of worsening depression and identified that the patient stated s/he was feeling very hopeless and had no reason to live. The note identified patient would be monitored overnight and evaluated by crisis the next morning for worsening thoughts of suicide with no plan.

A physician's order dated 3/7/23 directed suicide precautions including continuous observation with patient safety attendant.

An interview who ED Technician #4 on 4/11/23 at 12:34 PM identified she was sitting for 3 patients to include Patient #25 and #27 on the day that Patient #27 eloped. ED Technician #4 identified that Patient #27 walked out of sight, and she went after Patient #27. ED Technician #4 stated that at the time she pursued Patient #27 she was unable to observe the other patients she was assigned to observe. Technician #4 identified the ED did not have adequate staffing and stated that at one point she sat with 4 patients at the same time. Technician #4 stated she cannot do the best job keeping her eyes on 4 patients at once.

Interview with Manager #1 (ED) on 4/11/23 at 12:39 PM identified that continuous observation meant staff was able to always visualize the patient. Manager #1 indicated that Technician #4 should not have left other patients on continuous observation unattended and gone after the eloping patient.

An interview with the Staff Educator on 4/12/23 at 3:00 PM identified when physician's order directs constant observation for a patient who is suicidal, the patient should be on 1:1 observation and the attendant should not be watching other patients at the same time.

Review of the Patient Observation and Safety policy directed the purpose of the policy was to provide an environment that assures the safety of patients and personnel through a systematic plan of patient observation. The policy directed that nursing staff would observe each patient as per the provider order either every 5-minutes, 15-minutes, or constant observation.

The Hospital's policy did not address the use of 1:1 sitter for patients triaged with suicidal ideation.

Based on clinical record reviews, observation, and interviews for 2 of 6 patients reviewed for identification (Patients #9, 12), the hospital failed to ensure that patients were identifiable when they were observed without wearing identification bracelets. The findings include:


a. Observation on the in-patient geri-psych behavioral health unit with the Program Director on 4/10/23 at 9:00 AM identified that Patient #9 did not have a patient identification bracelet on, and there was no care plan for an alternative if the patient refused to wear it.

b. Observation on the in-patient adult behavioral health unit with the Program Director on 4/10/23 at 9:00 AM identified that Patient #12 did not have a patient identification bracelet on, and there was no care plan for an alternative if the patient refused to wear it.

Interview with the Program Director on 4/10/23 at 9:30 AM identified that it was hospital policy for all patients to have an identification bracelet on or a care plan for an alternative if the patient refused to wear it. Patients #9 and #12 did not have care plans for refusal of patient identification bracelets.

Based on clinical record reviews, review of hospital documentation, interviews, and policy review for three of three sampled patients (Patient #42, #43, # 44) who were reviewed for medication administration, the hospital failed to ensure staff administered and documented medications consistent with the hospital's policy and practice. The findings include:

a. Patient #42 was admitted to the hospital with diagnosis to include withdrawal and hypokalemia.
A physician's order dated 4/1/23 directed Lorazepam (Ativan) 2 mgs every hour as needed for Clinical institute withdrawal Assessment for alcohol (CIWA) scores of 12-15.

Review of a hospital documentation identified that on 4/3/23 two - 2 mgs vials of Lorazepam were dispensed for Patient #42 but were never charted as given.

The administration documentation document identified Lorazepam 2 mgs administered at 3:45 AM and 6:03 AM on 4/3/23 were documented as given on 4/14/23 (11 days after dispensed).

b. Patient #43 was admitted to the hospital with a diagnosis of major depression and alcohol abuse.
The physician's order dated 4/5/23 directed Lorazepam tablet 3 mgs every 3 hours as needed for clinical institute withdrawal for alcohol score of 19-22.

Review of the hospital report identified Lorazepam 3 mgs was dispensed but never documented as administered.
Review of Patient #43's medication administration record with Pharmacist #1 identified the clinical record lacked documentation Lorazepam 3 mgs was documented as being administered to patient #43 during the patient's stay in the hospital.

c. Patient #44 was admitted to the hospital for an outpatient procedure. The physician's order dated 4/7/23 at 9:24 AM directed Midazolam 3 mgs intravenous.

Review of the hospital report identified midazolam 2 mgs was dispensed twice by override on 4/7/23 at 8:57 AM and 9:02 AM and 3 mgs was marked at being administered at 9:23 AM but the remaining 1 mg was not documented as wasted.

Interview with Pharmacist #1 on 4/17/23 at 3:45PM identified the pharmacists' process including looking back one day at dispensed medications versus administrations. Pharmacist #1 identified that where there are discrepancies internal reports were completed, and investigations initiated to include interviewing of staff involved and the review of camera footage for possible diversion. Pharmacist #1 identified that in the cases with Patient #'s 42, 43, and 44 the investigations determined there were no diversion of medications but determined staff failed to scan medications or did not document waste consistent with the expectations.

An interview with the Director of professional development on 4/17/23 at 4:00 PM identified it was the expectation that all medications are barcode scanned and documented to include documentation of waste, at the time of medication administration.

The medication ordering and administration policy identified the purpose as to define elements of safe medication administration, identified disposition of unused medications are to be managed according to hospital policy, directed the use of barcode medication administration as a safe medication administration practice, and directed to document medication administration in the medication administration record.