HospitalInspections.org

Based on a review of facility policies, video surveillance and staff interviews the Governing Body failed to ensure that the nursing staff adhered to facility policy and acceptable standards of care regarding medical emergencies. Specifically, the Governing Body failed to ensure that immediate actions were taken to mitigate future incidents when staff failed to respond in a timely manner to P#1's medical emergency. It was determined that the facility's Governing Body failed to ensure hospital operations as it related to the following deficiencies:

Findings Include:
Cross Refer A-0049 as it relates to the governing body's failure to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients.

Based on medical record review, video footage, policy and procedure, and staff interviews it was determined that the facility failed to protect and promote the rights of the patient. Specifically, P#1 experienced a medical emergency and staff failed to respond in a timely manner, resulting in death.

Findings Include:
Cross refer A-0145 as it relates to the facility's failure to ensure that Patient Rights were exercised by failing to ensure that P#1 was free from neglect.

Based on medical record review, video footage, staff interviews, observation, and policy review it was determined that the facility failed to ensure that P#1 was properly assessed and interventions taken in a timely manner during a medical emergency.

Findings Include:
Cross refer A-0398 as it refers to the facility's failure to ensure that all licensed nurses adhered to the policies and procedures when P#1 was found on the floor and experienced an emergency event.

Based on medical record review, video footage, staff interviews, and policy review it was determined that the facility failed to follow the established treatment plan and provide proper oversight for P#1 who was on continuous observation at the time he fell to the floor and experienced a medical emergency.

Findings Include:
Cross refer A-1640 as it refers to the facility's failure to ensure the treatment plan was comprehensive and met the individualized needs of P#1

Based on Medical record review, video footage, Governing body bylaws, and staff interviews it was determined that the facility failed to ensure that Medical Staff was accountable to the Governing Body for the quality of care of medical care provided to one (P) #1 of four sampled patients.

Findings Include:
A review of the medical record revealed P#1 was a 49-year-old male admitted on an involuntary hold from county jail to the facility on 8/28/25 at 10:02 a.m. diagnosed with bipolar disorder, episode depressed, and severe psychotic features.

A review of the nursing note dated 8/28/25 revealed upon arrival to Temporary Observation (Temp Obs) P#1 was verbally abusive, threatening and trying to hit staff. PA BB was present at the time and ordered Thorazine 100mg (antipsychotic medication) and Benadryl 50mg (sleep-aid); both to be given intramuscularly (IM) (by an injection into the muscle). The Campus supervisor was called for a show of support to administer medication. P#1 became more aggressive and 4-point restraints were initiated at 10:08 a.m. P#1 met release criteria at 10:31 a.m. and restraints were removed.

A review of the Client Doctors Orders dated 8/28/25 at 10:57 a.m. revealed an order was initiated for P#1 to be placed on continuous observation (CO) for aggression. Order expired on 8/29/25 at 11:30 a.m. Another order was written for CO to continue on 8/29/25 at 11:31 a.m. The order expired on 9/2/25 at 11:30 a.m.

A review of the Initial recovery plan dated 8/28/25 at 1:44 p.m. revealed P#1's was admitted to Adult Mental Health (AMH) Unit two. P#1's reason for admission was psychosis, mood instability, aggression and poor impulse control.

A review of the progress note dated 8/28/25 at 4:36 p.m. revealed P#1 was admitted to Unit 2 on CO for aggression. P#1 ambulated to the unit by staff no distress and no complaints. P#1 was oriented to his room, he showered, vital signs in normal range. P#1 displayed no aggression at that time.

A review of nurses progress note dated 8/28/25 at 7:21 p.m. revealed P#1 was displaying aggressive and disruptive behavior during dinner and threatening peers. P#1 was redirected several times, but his behavior escalated and PRN (as needed) medication was ordered.

A review of the Nursing Note dated 8/29/25 at 6:57 a.m. revealed P#1 remained on CO for aggression. P#1 was confused, manic, bizarre and actively pacing the unit. P#1 was given 100mg Thorazine IM and Benadryl 50 mg IM at 12:27 a.m. but that was not effective. P#1 began slamming doors, turning on lights and trying to wake up peers. P#1 was hard to redirect. Physician was notified and an order for Ativan (central nervous system depressant-sedative)4mg IM at 1:52 a.m. was given. P#1 was making threats to kill staff. He remained visible with continuous monitoring.

A review of Nursing note dated 8/29/25 at 2:36 p.m. revealed P#1 was still in CO for aggression. RN QQ documented that P#1 was intrusive and tried to bully peers, P#1 had been compliant with medications.

A review of Nursing progress note dated 8/29/25 at 6:15 p.m. revealed P#1 slept the initial part of the shift, but when he woke up he was agitated and Ativan 2mg by mouth was given.

A review of Nursing note dated 8/30/25 at 11:39 a.m. revealed P#1 was labile, intrusive and verbally aggressive with staff, banging on windows and yelling out. Show of support and campus supervisor notified. Ativan 2mg IM was given. P#1 was cooperative and tolerated without incident.

A review of Nursing/HST notes dated 8/30/25 at 10:20 p.m.. revealed floor staff reported P#1 stated that items were missing from his hygiene box. P#1 started throwing items from the tables to the floor, turned over trash bin, picked up a chair and threw it towards the wall, trying to hit the television. P#1 ignored staff redirection. Staff called code yellow. Security responded to code and P#1 took a fighting stance. Staff responding to code yellow stayed on the unit until P#1 calmed down and let medication nurse administer Ativan 2mg by mouth. P#1 sat in dayroom briefly then went to his room and went to bed.

A review of video footage from the facility's Unit 2 dayroom 8/31/25 at 8:49 a.m. revealed:
8:50 a.m. P#1 comes into view of the camera in the dayroom.
8:50:13 P#1 is seen swinging a blanket and hitting the "Wet Floor Sign"
8:50:42 P#1 is seen crouched down on the floor at the corner of a chair where another patient was sitting
8:51:13 P#1 falls backwards onto the floor.
8:51:40 RN MM enters the dayroom calling for patients to get medication and HA OO gets up from the chair where she was seated and walks in the line of site of P#1 and appeared to be looking at P#1 lying on the floor.
8:52:04 HA OO walked back to her seat and sat down.
8:52:58 RN MM enters the dayroom and continues to call patients for med pass, P#1 still lying on the floor.
8:53:19 RN NN enters dayroom, stands over P#1 and appeared to be calling his name.
8:53:51 HA OO gets up and walks over to RN NN and P#1 lying on the floor.
8:54:07 HA OO begins to shake P#1 using the blanket that was draped across his left shouder and torso.
8:54:28 HA OO seen leaving P#1 and going into the chart room.
8:54:38 HA GG seen getting up and walking towards RN NN and P#1 lying on the floor.
8:54:57 Heard RN NN calling for RN MM, then RN NN seen leaving the day room.
8:55:03 HA OO seen returning from chart room with monitor.
8:55:06 RN NN and RN MM seen in the back hall, neither re-enter the day room.
8:55:14 HA OO placed blood pressure cuff on forearm of P#1.
8:55:20 RN MM quickly entered and exits dayroom.
8:55:37 RN NN seen in back hall pointing towards P#1, RN NN does not re-enter the day room
8:55:47 RN MM entered the day room stands over P#1 and calls his name.
8:56:07 RN NN re-enters dayroom with a flashlight.
8:56:11 RN MM places his hand on P#1's chest
8:56:22 RN MM lifts up P#1's shirt.
8:56:34 RN NN enters chart room, RN MM kneeling over P#1
8:56:49 RN MM changes placement of the blood pressure cuff.
8:57:06 multiple staff members enter day room with crash cart.
8:58:08 Life saving measures begin, Chest compressions and Cardiopulmonary Resuscitation (CPR)
9:06:49 Fire Department enters and takes over CPR
9:11:28 EMS Enters and assist Fire Department with CPR
9:23:07 More EMS enters the dayroom
9:30:56 CPR is discontinued
9:32 a.m. Pronounced Deceased

A review of the "Governing Body of Georgia Regional Hospital bylaws" last approved 4-18-23, revealed the board had been established to provide services that included the diagnosis, care, and treatment or habilitation of the intellectually disabled and the mentally ill. Each individual admitted to or treated by the facility would receive care and treatment that would suit his or her needs and the least restrictive appropriate care and treatment. Such care and treatment would be administered skillfully, safely, and humanely with full respect for the individual's dignity and personal integrity. The Governing Body was accordingly authorized to act as the "Governing Body" of the facility for purposes of facility licensing, compliance, and quality of medical and nursing services and related purposes. The Governing Body would ensure that the facility's medical staff be accountable to the Governing Body for the quality of care provided to individuals treated by the facility. The Governing Body meets twice a year in April and October.

A telephone interview was conducted with Physician Assistant (PA) BB on 9/9/25 at 9:38 a.m. PA BB stated that he did the intake assessment on all new admissions and admitted patients to the appropriate unit. PA BB stated that he did remember P#1and that he was on the referral list for quite a while. PA BB stated that P#1 was in county jail in another city and the Sherriff or jail administration kept calling due to P#1 being extremely aggressive and expressed the urgency to have him admitted to the facility. The facility did not have any male beds so P#1was placed on high priority for admission. PA BB stated that a bed soon become available so he approved the transfer from the jail to the facility. PA BB stated that when P#1 arrived at the facility he was sitting in the processing/intake room staring like he was paranoid. PA BB stated that P#1 stepped out of the processing/intake room where he and a few employees were standing and said, "If one of yall touch me, Im gonna kill yall" PA BB stated for everyone's safety, he ordered medication to help calm P#1 down. PA BB stated that he ordered Thorazine (antipsychotic medication) 100mg IM and Benadryl 50mg IM (antihistamine used to treat allergy symptoms, insomnia, motion sickness and some cold symptoms). P#1 was then placed in four-point restraints after medication was given. PA BB stated that once the medications took effect which was about 15 minutes, the restraints were removed. PA BB stated that after the medications became effective P#1 was calm, cooperative and no longer making threats. PA BB stated that he was able to do a physical exam and was able to talk to him a little more. PA BB stated that P#1 presented as a manic with psychotic features and had a lot of grandiose ideas and paranoid delusions.

PA BB stated that he thought that P#1 needed in patient stabilization so he admitted P#1 to Unit two and ordered medications, Seroquel (antipsychotic medication) and Depakote (mood stabilizer). PA BB stated that around 6:30 p.m. he received a call that P#1 was acting erratic, threatening and throwing tables and things at staff. PA BB stated that he went to the unit and P#1 was given his PRN (pro re nata) (as needed) medications. PA BB stated that he sat with one of the techs and they watched P#1 for a little bit, but P#1 still seemed agitated and made a threat to another patient that was in the phone booth. PA BB stated about 30 minutes passed and he went and spoke with the P#1 and asked him if he would be willing to take some of his night time medication so he could sleep and P#1agreed. PA BB stated that he called back one hour later and staff said that P#1 was calm.

PA BB further that he heard about the death of P#1 on Sunday 8/31/25. PA BB stated that he spoke with the nurse to go over what medications P#1 had been given. PA BB stated that he was advised that P#1 did not have any medication the morning of 8/31/25. PA BB stated that he was advised by the nurse that the last dose of medication P#1 was given was midnight the night before.

An interview was conducted with RN NN on 9/9/25 at 3:59 p.m. in the conference room. RN NN stated the she did P#1's admission to unit two and he was ok when she did his examination. RN NN stated that later on the evening of 8/28/25 staff reported that P#1 was disruptive and wanted to fight. RN NN stated that she had to go into the system several times to document because his behavior had changed. RN NN stated when she returned to work on Saturday 8/30/25 P#1 appeared to be threatening, disruptive and manic, stating that he wanted to kill people. RN NN stated that P#1 received PRN medication and she had to do an incident report due to his behavior. RN NN stated that the morning of Sunday 8/31/25 when she came back to work, she saw P#1 sleeping in the chair, in the day room. RN NN stated that she was on the female side and then she went on the male side to advise them about the breakfast food trays and she opened the door and saw P#1 laying on the floor. RN NN stated that she asked HA OO why P#1 was on the floor and HA OO stated that P#1 placed himself on the floor and he was ignoring her. RN NN stated that she called P#1 by his last name and he did not respond, but when she called his first name, he looked up. RN NN stated that she asked HA OO to get the vitals machine and she called for a male nurse RN MM for assistance. RN NN stated that she thought if they could get his vital signs they could get him off the floor. RN NN stated when RN MM checked his vitals they were threaded so they called a code. RN PP came over from the female side and she checked P#1's carotid and realized there was no pulse and that's when CPR was started. RN FF acknowledged that when a patient was in distress and goes down to the floor the pulse should be checked but she had a medical problem that's why she called RN MM to do the assessment on P#1. RN FF stated that she was not on any type of work restriction and no one knew about her medical condition. RN FF further stated that she could assess a patient but she could not get down on the floor at that time because she was taking medication and needed to go to the bathroom immediately.

An interview was conducted with HA OO on 9/9/25 at 4:11 p.m. in the conference room. HA OO stated that Sunday 8/31/25 was her first time meeting P#1 and she was assigned to him for observation every 15 minutes. HA OO stated that after she received report and checked on the two patients she had for observation she sat down because P#1 was sitting in the chair sleeping. HA OO stated when P#1 woke up she spoke to him and introduced herself. HA OO stated that she encouraged P#1 to get up use the bathroom, take his medication and eat breakfast and he did not want to move. HA OO stated that P#1 put the cover back on his head and went back to sleep. HA OO stated that she had a direct line of vision on both of the patients. HA OO stated that when EVS JJ came by to mop the day room floor P#1 was mad because he said EVS JJ didn't mop the floor correctly. HA OO stated that P#1 was talking to another patient and she saw him on the floor. HA OO stated she was talking to HA GG and told him that P#1 needed to get off the floor and HA GG said no he is fine, so HA OO said ok and let him stay on the floor. RN NN came in the day room and asked HA OO and HA GG why P#1 was on the floor and HA OO stated that HA GG said that as long as she could see him he was fine. HA OO stated when RN NN called P#1's name he had barely responding and HA OO stated she thought they needed to call a code. HA OO stated when the code was called for unit two there was a bit of confusion because a code had also been called for unit 3. HA OO said she thought that RN NN had checked P#1's pulse. HA OO further stated that she was told by the campus supervisor told her what codes to use on the observation sheet.

An interview was conducted with Clinical Director (CD) LL on 9/9/25 at 1:37 p.m.in the conference room. CD LL stated that he was not directly involved with P#1 on his admission. CD LL stated he received a call on Sunday 8/31/25 that P#1 had been in cardiac arrest so he came into facility. CD LL stated that he went through the coroner and requested an autopsy. CD LL stated that he did not hear anything about P#1 prior to his expiration. CD LL stated that after he was informed of P#1 expiring, he wanted to know more about P#1's medical history.. CD LL stated that he did request an autopsy from the corner, but no information had been provided to date.

Based on medical record review, video footage, policy and procedure, and staff interviews it was determined that the facility failed to ensure that Patient Rights were exercised by failing to ensure that P#1 was free from neglect.

Findings include:

A review of the medical record revealed P#1 was a 49-year-old male admitted on an involuntary hold from county jail to the facility on 8/28/25 at 10:02 a.m. diagnosed with bipolar disorder, episode depressed, and severe psychotic features.

A review of the nursing note dated 8/28/25 revealed upon arrival to Temporary Observation (Temp Obs) P#1 was verbally abusive, threatening and trying to hit staff. PA BB was present at the time and ordered Thorazine 100mg IM (antipsychotic medication) and Benadryl 50mg IM (sleep-aid). The Campus supervisor was called for a show of support to administer medication. P#1 became more aggressive and 4-point restraints were initiated at 10:08 a.m. P#1 met release criteria at 10:31 a.m. and restraints were removed.

A review of the Client Doctors Orders dated 8/28/25 at 10:57 a.m. revealed an order was initiated for P#1 to be placed on continuous observation (CO) for aggression. Order expired on 8/29/25 at 11:30 a.m. Another order was written for CO to continue on 8/29/25 at 11:31 a.m.

A review of the Initial recovery plan dated 8/28/25 at 1:44 p.m. revealed P#1's was admitted to Adult Mental Health (AMH) Unit two. P#1's reason for admission was psychosis, mood instability, aggression and poor impulse control.
A review of the progress note dated 8/28/25 at 4:36 p.m. revealed P#1 was admitted to Unit 2 on CO for aggression. P#1 ambulated to the unit by staff no distress and no complaints. P#1 was oriented to his room, he showered, vital signs in normal range. P#1 displayed no aggression at that time.

A review of nurses progress note dated 8/28/25 at 7:21 p.m. revealed P#1 was displaying aggressive and disruptive behavior during dinner and threatening peers. P#1 was redirected several times, but his behavior escalated and a PRN medication was ordered.

A review of the Nursing Note dated 8/29/25 at 6:57 a.m. revealed P#1 remained on CO for aggression. P#1 was confused, manic, bizarre and actively pacing the unit. P#1 was given 100mg Thorazine IM and Benadryl 50 mg IM at 12:27 a.m. but that was not effective. P#1 began slamming doors, turning on lights and trying to wake up peers. P#1 was hard to redirect. Physician was notified and an order for Ativan (central nervous system depressant-sedative)4mg IM at 1:52 a.m. was given. P#1 was making threats to kill staff. He remained visible with continuous monitoring.

A review of Nursing note dated 8/29/25 at 2:36 p.m. revealed P#1 was still in CO for aggression. RN QQ documented that P#1 was intrusive and tried to bully peers, P#1 had been compliant with medications.

A review of Nursing progress note dated 8/29/25 at 6:15 p.m. revealed P#1 slept the initial part of the shift, but when he woke up he was agitated and Ativan 2mg by mouth was given.

A review of Nursing note dated 8/30/25 at 11:39 a.m. revealed P#1 was labile, intrusive and verbally aggressive with staff, banging on windows and yelling out. Show of support and campus supervisor notified. Ativan 2 mg by mouth was given. P#1 was cooperative and tolerated without incident.

A review of Nursing/HST notes dated 8/30/25 at 10:20 p.m.. revealed floor staff reported P#1 stated that items were missing from his hygiene box. P#1 started throwing items from the tables to the floor, turned over trash bin, picked up a chair and threw it towards the wall, trying to hit the television. P#1 ignored staff redirection. Staff called code yellow. Security responded to code and P#1 took a fighting stance. Staff responding to code yellow stayed on the unit until P#1 calmed down and let medication nurse administer Ativan 2mg by mouth. P#1 sat in dayroom briefly then went to his room and went to bed.

Video Footage
A review of video footage from the facility's Unit 2 dayroom 8/31/25 at 8:49 a.m. revealed:
8:50 a.m. P#1 comes into view of the camera in the dayroom.
8:50:13 P#1 is seen swinging a blanket and hitting the "Wet Floor Sign"
8:50:42 P#1 is seen crouched down on the floor at the corner of a chair where another patient was sitting
8:51:13 P#1 falls backwards onto the floor.
8:51:40 RN MM enters the dayroom calling for patients to get medication and HA OO gets up from the chair where she was seated and walks in the line of site of P#1 and appeared to see P#1 lying on the floor.
8:52:04 HA OO walked back to her seat and sat down.
8:52:58 RN MM enters the dayroom and continues to call patients for med pass, P#1 still lying on the floor.
8:53:19 RN NN enters dayroom, stands over P#1and appeared to be calling his name.
8:53:51 HA OO gets up and walks over to RN NN and P#1 lying on the floor.
8:54:07 HA OO begins to shake P#1 using the blanket that was draped over his left shoulder and torso.
8:54:28 HA OO seen leaving P#1 and going into the chart room.
8:54:38 HA GG seen getting up and walking towards RN NN and P#1 lying on the floor.
8:54:57 Heard RN NN calling for RN MM, then RN NN seen leaving the day room.
8:55:03 HA OO seen returning from chart room with monitor.
8:55:06 RN NN and RN MM seen in the back hall, neither re-enter the day room.
8:55:14 HA OO placed blood pressure cuff on forearm of P#1.
8:55:20 RN MM quickly entered and exits dayroom.
8:55:37 RN NN seen in back hall pointing towards P#1, RN NN does not re-enter the day room
8:55:47 RN MM entered the day room stands over P#1 and calls his name.
8:56:07 RN NN re-enters dayroom with a flashlight.
8:56:11 RN MM places his hand on P#1's chest
8:56:22 RN MM lifts up P#1's shirt.
8:56:34 RN NN enters chart room, RN MM kneeling over P#1
8:56:49 RN MM changes placement of the blood pressure cuff.
8:57:06 multiple staff members enter day room with crash cart.
8:58:08 Life saving measures begin, Chest compressions and Cardiopulmonary Resuscitation (CPR)
9:06:49 Fire Department enters and takes over CPR
9:11:28 EMS Enters and assist Fire Department with CPR
9:23:07 More EMS enters the dayroom
9:30:56 CPR is discontinued
9:32 a.m. Pronounced Deceased

A review of the facility's policy titled "Individuals' Rights", #24-103, last reviewed 1-24-23, revealed DBHDD recognized and respected the rights of all individuals. Individuals who received services in DBHDD hospitals, as well as staff who provide these services, would be informed of these rights and their responsibilities. 290-4-9-.02 Treatment. 1. Appropriateness. (a) General. Each client would receive care that would be suited to his needs in the least restrictive environment available offering appropriate care and treatment or habilitation. All clients had the right to a humane treatment or habilitation environment that affords reasonable protection from harm, exploitation or coercion. Protection of the client's well-being would be of primary concern to all staff under all circumstances. (g)Medications. 2. All medications would be administered or prescribed solely for the purpose of providing effective treatment or habilitation and/or protecting the safety of the client and other persons and would not be used as punishment or for the convenience of staff. 3. If not judicially declared incompetent, all adults would give signed consent to the administration of medication. 290-4-9-.03 Treatment. (2) Abuse and Sexual Activity. (a) Abuse of any client would be prohibited. No staff member would abuse any client through physical or verbal attack, exploitation, or coercion.

An interview was conducted with Clinical Director (CD) LL on 9/9/25 at 1:37 p.m.in the conference room. CD LL stated that he was not directly involved with P#1 on his admission. CD LL stated he received a call on Sunday 8/31/25 that P#1 had been In cardiac arrest so he came into facility. CD LL stated that he went through the corner and requested an autopsy. CD LL stated that he did not hear anything about P#1 prior to his expiration. CD LL stated that after he was informed of P#1 expiring, he wanted to know more about P#1's medical history. CD LL stated that he did request an autopsy from the corner, but no information had been provided to date.

An interview was conducted with HA OO on 9/9/25 at 4:11 p.m. in the conference room. HA OO stated that Sunday 8/31/25 was her first time meeting P#1 and she was assigned to him for observation every 15 minutes. HA OO stated that after she received report and checked on the two patients she had for observation she sat down because P#1 was sitting in the chair sleeping. HA OO stated when P#1 woke up she spoke to him and introduced herself. HA OO stated that she encouraged P#1 to get up use the bathroom, take his medication and eat breakfast and he did not want to move. HA OO stated that P#1 put the cover back on his head and went back to sleep. HA OO stated that she had a direct line of vision on both of the patients. HA OO stated that when EVS JJ came by to mop the day room floor P#1 was mad because he said EVS JJ didn't mop the floor correctly. HA OO stated that P#1 was talking to another patient and she saw him on the floor. HA OO stated she was talking to HA GG and told him that P#1 needed to get off the floor and HA GG said no he is fine, so HA OO said ok and let him stay on the floor. RN NN came in the day room and asked HA OO and HA GG why P#1 was on the floor and HA OO stated that HA GG said that as long as she could see him he was fine. HA OO stated when RN NN called P#1's name he had barely responding and HA OO stated she thought they needed to call a code. HA OO stated when the code was called for unit two there was a bit of confusion because a code had also been called for unit 3. HA OO said she thought that RN NN had checked P#1's pulse. HA OO further stated that she was told by the campus supervisor told her what codes to use on the observation sheet.

An interview was conducted with HA GG on 9/9/25 at 10:53 a.m. in the conference room. HA GG stated that P#1 was admitted to unit two the evening of Thursday 8/28/25 right before his shift ended. HA GG stated that on Friday 8/29/25 he worked with P#1 and he was laughing and talking. HA GG further stated that Saturday 8/30/25 when he came back to work P#1 was talking to Environmental Services (EVS) JJ and told him that he didn't mop the floor well so P#1 got down on the floor to show EVS JJ what to do. HA GG stated that P#1 got down on the floor because he liked laying on the floor. HA GG stated that after P#1 laid on the floor in the day room he told HA OO she needed to check on P#1 because he didn't look like he was getting up. HA GG stated that P#1 did not get up and they initiated a code blue. HA GG further stated that P#1 had not been hurting or complaining about anything. HA stated that P#1 was on unit two for aggression but he wasn't really aggressive.

An interview was conducted with RN NN on 9/9/25 at 3:59 p.m. in the conference room. RN NN stated the she did P#1's admission to unit two and he was ok when she did his examination. RN NN stated that later on the evening of 8/28/25 staff reported that P#1 was disruptive and wanted to fight. RN NN stated that she had to go into the system several times to document because his behavior had changed. RN NN stated when she returned to work on Saturday 8/30/25 P#1 appeared to be threatening, disruptive and manic, stating that he wanted to kill people. RN NN stated that P#1 received PRN medication and she had to do an incident report due to his behavior. RN NN stated that the morning of Sunday 8/31/25 when she came back to work, she saw P#1 sleeping in the chair, in the day room. RN NN stated that she was on the female side and then she went on the male side to advise them about the breakfast food trays and she opened the door and saw P#1 laying on the floor. RN NN stated that she asked HA OO why P#1 was on the floor and HA OO stated that P#1 placed himself on the floor and he was ignoring her. RN NN stated that she called P#1 by his last name and he did not respond, but when she called his first name, he looked up. RN NN stated that she asked HA OO to get the vitals machine and she called for RN MM for assistance. RN NN stated that she thought if they could get his vital signs they could get him off the floor. RN NN stated when RN MM checked his vitals they were thready so they called a code.

An interview was conducted with Regional Hospital Administrator (RHA) SS on 9/10/25 at 3:00 p.m. in the conference room. RHA SS stated that when the nursing department has a vacancy they would submit a request to hire that goes through a process. Once the position has been approved by all involved then it gets posted and once hired Human Resources will handle all other pertinent information. RHA SS stated that health exams were done on hire and health screenings were done annually. RHA SS stated that the facility required the same information for agency nurses as they do for nurses employed by the facility.

RHA SS stated that she was not aware that RN NN had any health problems that would prohibit her from performing her job responsibilities. RHA SS stated when she met with the group of staff involved in the incident to discuss the incident concerning P#1, RN NN stated that she had an emergency she was dealing with. RHA SS stated that HS OO admitted that she saw P#1 on the floor and she didn't bother him because earlier in the day she had tried to interact with him and he did want to be bothered with her so when she saw him on the floor she didn't bother him.
RHA SS stated that after the incident with P#1 on 8/31/25, leadership started on the paperwork and the video was not immediately reviewed.

Based on medical record review, video footage, staff interviews, observation and policy review it was determined that the facility failed to ensure that patient needs were met by ongoing assessments and provided nursing staff to meet those needs.

Findings Include:
A review of the medical record revealed P#1 was a 49-year-old male admitted on an involuntary hold from county jail to the facility on 8/28/25 at 10:02 a.m. diagnosed with bipolar disorder, episode depressed, and severe psychotic features.

A review of the nursing note dated 8/28/25 revealed upon arrival to Temporary Observation (Temp Obs) P#1 was verbally abusive, threatening and trying to hit staff. PA BB was present at the time and ordered Thorazine 100mg IM (antipsychotic medication) and Benadryl 50mg IM (sleep-aid). The Campus supervisor was called for a show of support to administer medication. P#1 became more aggressive and 4-point restraints were initiated at 10:08 a.m. P#1 met release criteria at 10:31 a.m. and restraints were removed.

A review of the Client Doctors Orders dated 8/28/25 at 10:57 a.m. revealed an order was initiated for P#1 to be placed on continuous observation (CO) for aggression. Order expired on 8/29/25 at 11:30 a.m. Another order was written for CO to continue on 8/29/25 at 11:31 a.m.

A review of the Initial recovery plan dated 8/28/25 at 1:44 p.m. revealed P#1's was admitted to Adult Mental Health (AMH) Unit two. P#1's reason for admission was psychosis, mood instability, aggression and poor impulse control.

A review of the progress note dated 8/28/25 at 4:36 p.m. revealed P#1 was admitted to Unit 2 on CO for aggression. P#1 ambulated to the unit by staff no distress and no complaints. P#1 was oriented to his room, he showered, vital signs in normal range. P#1 displayed no aggression at that time.

A review of nurses progress note dated 8/28/25 at 7:21 p.m. revealed P#1 was displaying aggressive and disruptive behavior during dinner and threatening peers. P#1 was redirected several times, but his behavior escalated and a PRN medication was ordered.

A review of the Nursing Note dated 8/29/25 at 6:57 a.m. revealed P#1 remained on CO for aggression. P#1 was confused, manic, bizarre and actively pacing the unit. P#1 was given 100mg Thorazine IM and Benadryl 50 mg IM at 12:27 a.m. but that was not effective. P#1 began slamming doors, turning on lights and trying to wake up peers. P#1 was hard to redirect. Physician was notified and an order for Ativan 4mg IM at 1:52 a.m. was given. P#1 was making threats to kill staff. He remained visible with continuous monitoring.

A review of Nursing note dated 8/29/25 at 2:36 p.m. revealed P#1 was still in CO for aggression. RN QQ documented that P#1 was intrusive and tried to bully peers, P#1 had been compliant with medications.

A review of Nursing progress note dated 8/29/25 at 6:15 p.m. revealed P#1 slept the initial part of the shift, but when he woke up he was agitated PRN Ativan 2mg (central nervous system depressant-sedative) was given.

A review of Nursing note dated 8/30/25 at 11:39 a.m. revealed P#1 was labile, intrusive and verbally aggressive with staff, banging on windows and yelling out. Show of support and campus supervisor notified. Ativan 2 mg by mouth was given. P#1 was cooperative and tolerated without incident.

A review of Nursing/HST notes dated 8/30/25 at 10:20 p.m.. revealed floor staff reported P#1 stated that items were missing from his hygiene box. P#1 started throwing items from the tables to the floor, turned over trash bin, picked up a chair and threw it towards the wall, trying to hit the television. P#1 ignored staff redirection. Staff called a code yellow. Security responded to code and P#1 took a fighting stance. Staff responding to code yellow stayed on the unit until P#1 calmed down and let medication nurse administer Ativan 2mg by mouth. P#1 sat in dayroom briefly then went to his room and went to bed.

Video Footage
A review of video footage from the facility's Unit 2 dayroom 8/31/25 at 8:49 a.m. revealed:
8:50 a.m. P#1 comes into view of the camera in the dayroom.
8:50:13 P#1 is seen swinging a blanket and hitting the "Wet Floor Sign"
8:50:42 P#1 is seen crouched down on the floor at the corner of a chair where another patient was sitting
8:51:13 P#1 falls backwards onto the floor.
8:51:40 RN MM enters the dayroom calling for patients to get medication and HA OO gets up from the chair where she was seated and walks in the line of site of P#1 and appeared to be looking at P#1 lying on the floor.
8:52:04 HA OO walked back to her seat and sat down.
8:52:58 RN MM enters the dayroom and continues to call patients for med pass, P#1 still lying on the floor.
8:53:19 RN NN enters dayroom, stands over P#1 and appeared to be calling his name.
8:53:51 HA OO gets up and walks over to RN NN and P#1 lying on the floor.
8:54:07 HA OO begins to shake P#1 using the blanket that was draped over his left shoulder and torso.
8:54:28 HA OO seen leaving P#1 and going into the chart room.
8:54:38 HA GG seen getting up and walking towards RN NN and P#1 lying on the floor.
8:54:57 Heard RN NN calling for RN MM, then RN NN seen leaving the day room.
8:55:03 HA OO seen returning from chart room with monitor.
8:55:06 RN NN and RN MM seen in the back hall, neither re-enter the day room.
8:55:14 HA OO placed blood pressure cuff on forearm of P#1.
8:55:20 RN MM quickly entered and exits dayroom.
8:55:37 RN NN seen in back hall pointing towards P#1, RN NN does not re-enter the day room
8:55:47 RN MM entered the day room stands over P#1 and calls his name.
8:56:07 RN NN re-enters dayroom with a flashlight.
8:56:11 RN MM places his hand on P#1's chest
8:56:22 RN MM lifts up P#1's shirt.
8:56:34 RN NN enters chart room, RN MM kneeling over P#1
8:56:49 RN MM changes placement of the blood pressure cuff.
8:57:06 multiple staff members enter day room with crash cart.
8:58:08 Life saving measures begin, Chest compressions and Cardiopulmonary Resuscitation (CPR)
9:06:49 Fire Department enters and takes over CPR
9:11:28 EMS Enters and assist Fire Department with CPR
9:23:07 More EMS enters the dayroom
9:30:56 CPR is discontinued
9:32 a.m. Pronounced Deceased

An interview was conducted with HA GG on 9/9/25 at 10:53 a.m. in the conference room. HA GG stated that P#1 was admitted to unit two the evening of Thursday 8/28/25 right before his shift ended. HA GG stated that on Friday 8/29/25 he worked with P#1 and he was laughing and talking. HA GG further stated that Saturday 8/30/25 when he came back to work P#1 was talking to Environmental Services (EVS) JJ and told him that he didn't mop the floor well so P#1 got down on the floor to show EVS JJ what to do. HA GG stated that P#1 got down on the floor because he liked laying on the floor. HA GG stated that after P#1 laid on the floor in the day room he told HA OO she needed to check on P#1 because he didn't look like he was getting up. HA GG stated that P#1 did not get up and they initiated a code blue. HA GG further stated that P#1 had not been hurting or complaining about anything. HA stated that P#1 was on unit two for aggression but he wasn't really aggressive.

An interview was conducted with RN NN on 9/9/25 at 3:59 p.m. in the conference room. RN NN stated the she did P#1's admission to unit two and he was ok when she did his examination. RN NN stated that later on the evening of 8/28/25 staff reported that P#1 was disruptive and wanted to fight. RN NN stated that she had to go into the system several times to document because his behavior had changed. RN NN stated when she returned to work on Saturday 8/30/25 P#1 appeared to be threatening, disruptive and manic, stating that he wanted to kill people. RN NN stated that P#1 received PRN medication and she had to do an incident report due to his behavior. RN NN stated that the morning of Sunday 8/31/25 when she came back to work, she saw P#1 sleeping in the chair, in the day room. RN NN stated that she was on the female side and then she went on the male side to advise them about the breakfast food trays and she opened the door and saw P#1 laying on the floor. RN NN stated that she asked HA OO why P#1 was on the floor and HA OO stated that P#1 placed himself on the floor and he was ignoring her. RN NN stated that she called P#1 by his last name and he did not respond, but when she called his first name, he looked up. RN NN stated that she asked HA OO to get the vitals machine and she called for a male nurse RN MM for assistance. RN NN stated that she thought if they could get his vital signs they could get him off the floor. RN NN stated when RN MM checked his vitals they were threaded so they called a code. RN PP came over from the female side and she checked P#1's carotid and realized there was no pulse and that's when CPR was started. RN FF acknowledged that when a patient was in distress and goes down to the floor the pulse should be checked but she had a medical problem that's why she called RN MM to do the assessment on P#1. RN FF stated that she was not on any type of work restriction and no one knew about her medical condition. RN FF further stated that she could assess a patient but she could not get down on the floor at that time because she was taking medication and needed to go to the bathroom immediately.

An interview was conducted with HA OO on 9/9/25 at 4:11 p.m. in the conference room. HA OO stated that Sunday 8/31/25 was her first time meeting P#1 and she was assigned to him for observation every 15 minutes. HA OO stated that after she received report and checked on the two patients she had for observation she sat down because P#1 was sitting in the chair sleeping. HA OO stated when P#1 woke up she spoke to him and introduced herself. HA OO stated that she encouraged P#1 to get up use the bathroom, take his medication and eat breakfast and he did not want to move. HA OO stated that P#1 put the cover back on his head and went back to sleep. HA OO stated that she had a direct line of vision on both of the patients. HA OO stated that when EVS JJ came by to mop the day room floor P#1 was mad because he said EVS JJ didn't mop the floor correctly. HA OO stated that P#1 was talking to another patient and she saw him on the floor. HA OO stated she was talking to HA GG and told him that P#1 needed to get off the floor and HA GG said no he is fine, so HA OO said ok and let him stay on the floor. RN NN came in the day room and asked HA OO and HA GG why P#1 was on the floor and HA OO stated that HA GG said that as long as she could see him he was fine. HA OO stated when RN NN called P#1's name he had barely responding and HA OO stated she thought they needed to call a code. HA OO stated when the code was called for unit two there was a bit of confusion because a code had also been called for unit 3. HA OO said she thought that RN NN had checked P#1's pulse. HA OO further stated that she was told by the campus supervisor told her what codes to use on the observation sheet.

An interview was conducted with Regional Hospital Administrator (RHA) SS on 9/10/25 at 3:00 p.m. in the conference room. RHA SS stated that when the nursing department has a vacancy they would submit a request to hire that goes through a process. Once the position has been approved by all involved then it gets posted and once hired Human Resources will handle all other pertinent information. RHA SS stated that health exams were done on hire and health screenings were done annually. RHA SS stated that the facility required the same information for agency nurses as they do for nurses employed by the facility.

RHA SS stated that she was not aware that RN NN had any health problems that would prohibit her from performing her job responsibilities. RHA SS stated when she met with the group of staff involved in the incident to discuss the incident concerning P#1, RN NN stated that she had an emergency she was dealing with. RHA SS stated that HS OO admitted that she saw P#1 on the floor and she didn't bother him because earlier in the day she had tried to interact with him and he did want to be bothered with her so when she saw him on the floor she didn't bother him.
RHA SS stated that after the incident with P#1 on 8/31/25, leadership started on the paperwork and the video was not immediately reviewed.

A review of the facility's policy titled, "Medical Emergency Response System", #03-205-SV, last reviewed 11-28-23, revealed the facility utilizes an Medical Emergency Response System to organize, train, equip and provide immediate on-site response, assessment, and initial care of individuals who receive services who have an emergent medical condition pending the arrival of Emergency Medical Services (EMD) and transfer to an acute care hospital as applicable.

When individuals experience an emergent medical condition, the facility immediately would notify Emergency Medical Services (EMS) and provide timely Basic Life Support (BLS) and Basic First Aid (BFA) interventions in accordance with the American Heart Association (AHA) or American Red Cross (ARC) guidelines. Upon the arrival of EMS personnel, hospital staff would transfer responsibility for the care of the individual and provide assistance as requested by EMS personnel. Individuals would be transferred to an acute care hospital in a timely manner when treatment needed to exceed the hospital's scope of services.

Based on medical record review, video footage, staff interviews, and policy review it was determined that the facility failed to ensure staff followed the established treatment plan and that the plan was comprehensive and met the individualized needs of P#1 who was on continuous observation when he experienced an emergency condition and expired.

Findings Include:

A review of the medical record revealed P#1 was a 49-year-old male admitted on an involuntary hold from county jail to the facility on 8/28/25 at 10:02 a.m. diagnosed with bipolar disorder, episode depressed, and severe psychotic features.

A review of the Client Doctors Orders dated 8/28/25 at 10:57 a.m. revealed an order was initiated for P#1 to be placed on continuous observation (CO) for aggression. Order expired on 8/29/25 at 11:30 a.m. Another order was written for CO to continue on 8/29/25 at 11:31 a.m. The order expired on 9/2/25 at 11:30 a.m.

A review of video footage from the facility's Unit 2 dayroom 8/31/25 at 8:49 a.m. revealed:
8:50 a.m. P#1 comes into view of the camera in the dayroom.
8:50:13 P#1 is seen swinging a blanket and hitting the "Wet Floor Sign"
8:50:42 P#1 is seen crouched down on the floor at the corner of a chair where another patient was sitting
8:51:13 P#1 falls backwards onto the floor.
8:51:40 RN MM enters the dayroom calling for patients to get medication and HA OO gets up from the chair where she was seated and walks in the line of site of P#1 and appeared to be looking at him lying on the floor.
8:52:04 HA OO walked back to her seat and sat down.
8:52:58 RN MM enters the dayroom and continues to call patients for med pass, P#1 still lying on the floor.
8:53:19 RN NN enters dayroom, stands over P#1 and appeared to be calling his name.
8:53:51 HA OO gets up and walks over to RN NN and P#1 lying on the floor.
8:54:07 HA OO begins to shake P#1 using the blanket that was draped over his left shoulder and torso.
8:54:28 HA OO seen leaving P#1 and going into the chart room.
8:54:38 HA GG seen getting up and walking towards RN NN and P#1 lying on the floor.
8:54:57 Heard RN NN calling for RN MM, then RN NN seen leaving the day room.
8:55:03 HA OO seen returning from chart room with monitor.
8:55:06 RN NN and RN MM seen in the back hall, neither re-enter the day room.
8:55:14 HA OO placed blood pressure cuff on forearm of P#1.
8:55:20 RN MM quickly entered and exits dayroom.
8:55:37 RN NN seen in back hall pointing towards P#1, RN NN does not re-enter the day room
8:55:47 RN MM entered the day room stands over P#1 and calls his name.
8:56:07 RN NN re-enters dayroom with a flashlight.
8:56:11 RN MM places his hand on P#1's chest
8:56:22 RN MM lifts up P#1's shirt.
8:56:34 RN NN enters chart room, RN MM kneeling over P#1
8:56:49 RN MM changes placement of the blood pressure cuff.
8:57:06 multiple staff members enter day room with crash cart.
8:58:08 Life saving measures begin, Chest compressions and Cardiopulmonary Resuscitation (CPR)
9:06:49 Fire Department enters and takes over CPR
9:11:28 EMS Enters and assist Fire Department with CPR
9:23:07 More EMS enters the dayroom
9:30:56 CPR is discontinued
9:32 a.m. Pronounced Deceased

An interview was conducted with HA OO on 9/9/25 at 4:11 p.m. in the conference room. HA OO stated that Sunday 8/31/25 was her first time meeting P#1 and she was assigned to him for observation every 15 minutes. HA OO stated that after she received report and checked on the two patients she had for observation she sat down because P#1 was sitting in the chair sleeping. HA OO stated when P#1 woke up she spoke to him and introduced herself. HA OO stated that she encouraged P#1 to get up use the bathroom, take his medication and eat breakfast and he did not want to move. HA OO stated that P#1 put the cover back on his head and went back to sleep. HA OO stated that she had a direct line of vision on both of the patients. HA OO stated that when EVS JJ came by to mop the day room floor P#1 was mad because he said EVS JJ didn't mop the floor correctly. HA OO stated that P#1 was talking to another patient and she saw him on the floor. HA OO stated she was talking to HA GG and told him that P#1 needed to get off the floor and HA GG said no he is fine, so HA OO said ok and let him stay on the floor. RN NN came in the day room and asked HA OO and HA GG why P#1 was on the floor and HA OO stated that HA GG said that as long as she could see him he was fine. HA OO stated when RN NN called P#1's name he had barely responding and HA OO stated she thought they needed to call a code. HA OO stated when the code was called for unit two there was a bit of confusion because a code had also been called for unit 3. HA OO said she thought that RN NN had checked P#1's pulse. HA OO further stated that she was told by the campus supervisor told her what codes to use on the observation sheet.

Review of the "Levels of Observation for Individuals" policy #03-501, reviewed 5/17/22, revealed the hospital used established procedures for three levels of observation that were appropriate for the clinical care needs of individuals being served. Routine Observation was maintaining a general awareness of the individual ' s whereabouts status by visually observing the individual at least every 30 minutes. Continuous observation was maintaining continuous knowledge and awareness of the individual ' s whereabouts through visual observation. One-to-one (1:1) Observation was maintaining continuous knowledge and awareness of the individual's whereabouts with at least one assigned staff that remained in such proximity to the individual as to be able to intervene and prevent actions that were unsafe to the individual and others. The primary purpose of observation was to provide safety for individuals during periods of distress when they were at risk of harm to themselves or others. Documentation of 1:1 observation was completed every 15 minutes on the observation flow sheet. The staff member providing 1:1 was assigned the sole responsibility of observing the individual and remaining within a distance to immediately intervene to protect the safety of the individual or others. The observer was not assigned other responsibilities during the time she was providing 1:1 observation. The observer remained with the individual until responsibility of the individual was transferred from one staff member to another. There would be no physical barriers between the individual and assigned staff. The nurse in charge, shift supervisor, or QIDP on duty for the shift were responsible for ensuring that the level of observation was appropriately maintained. The hospital administrator was responsible for ensuring that staff members attend training regarding observation levels. The nurse executive was responsible for routine monitoring of data in relation to observation practice and implications for staffing resources.