HospitalInspections.org

Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 CoP: Patient's Rights, 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship and 42 CFR 482.43 CoP: Discharge Planning.

The hospital failed to:
- Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital; (A-0057)
- Provide the hospital's contact information needed to submit a complaint/grievance; (A-0121)
- Follow their policy when they did not contact a patient's legal guardian (a person appointed to take care of and manage the rights of a person who is considered incapable), for one discharged patient (#9) of two discharged patient records reviewed; (A-0131)
- Investigate the sedation and intubation of one discharged patient with a mental health crisis Patient (#16) of four event reports reviewed; (A-0144)
- Investigate a patient abuse allegation for one discharged patient (#15) of four event reports reviewed; (A-0144)
- Investigate the handling of a weapon in the Emergency Department (ED) of one discharged psychiatric patient (#17) of four event reports reviewed; (A-0144)
- Provide a dedicated, secured, ligature (anything which could be used for the purpose of hanging or strangulation) resistant and psychiatric (relating to mental illness) safe patient environment for eight current patients that were located in a locked Behavioral Health Unit (BHU); (A-0144)
- Protect Patient #16 when he was chemically restrained, intubated and placed on a ventilator without a clinical indication; (A-0145)
- Protect Patient #17 when she was subjected to five separate attempts by the physician to place an arterial line (thin, flexible tube placed into an artery); (A-0145)
- Identify the use of sedating medications and intubation as a chemical restraint and failed to document non-restraining methods for behavior management for one patient (#16) of five discharged patient records reviewed with restraints; (A-0160)
- Ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) three discharged patients (#16, #20, and #21) of five restraint patient records reviewed; (A-0175)
- Ensure appropriate violent restraint assessment was completed for one discharged Patient (#16) of two violent restraint patients reviewed; (A-0178)
- Ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), for all provider staff; (A-0206)
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for 11 patients (#4, #5, #11, #12, #13, #14, #25, #26, #27, #28 and #29) of 19 patients observed; (A-0749)
- Label intravenous (IV, in the vein) antibiotic medications prepared by staff on the unit for four patients (#2, #14, #25 and #28) of six patients observed; (A-0749)
- Prepare a clean work surface, sanitize equipment and ensure the use of clean/ sterile (completely clean and free from germs) supplies prior to performing patient care for nine patients (#2, #6, #7, #11, #12, #14, #25, #26 and #27) of 19 patients observed; (A-0749)
- Remove expired food, label food with expiration dates, maintain the refrigerator temperature log, and maintain a cleaning schedule in the main kitchen; (A-0749)
- Remove expired supplies from the crash carts (mobile cart which contains emergency medical supplies and medications) on two units of 12 units observed; (A-0749)
- Remove tape adhesive residue from surfaces in patient care areas to create a cleanable surface on 16 units of 16 units observed; and (A-0749)
- Follow nationally recognized standards to maintain a sanitary environment. (A-0749)
- Notify a legal guardian of a patient's discharge for one discharged patient (#9) of two discharged patient records reviewed; (A-0800) and
- Ensure a safe discharge when the hospital allowed a suicidal (SI, thoughts of causing one's own death) patient with affidavits (a written statement confirmed by oath, for use as evidence in court) to leave against medical advice (AMA) without a mental health evaluation for one discharged patient (#16) of two discharged patient records reviewed. (A-0813)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body.

Please refer to A-0057, A-0121, A-0131, A-0144, A-0145, A-0160, A-0175, A-0178, A-0206, A-0749, A-0800 and A-0813.

Based on interview, policy review and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Conditions of Participation (CoP): Patient's Rights, 42 CFR 482.43 CoP: Discharge Planning and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship.

These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's undated document titled, "St. Joseph Medical Center Organizational Chart," showed that all administrative leaders reported to Staff K, CEO.

Review of the hospital's document titled, "St. Joseph Medical Center Medical Staff Bylaws," approved 07/21/21, showed the CEO is the highest-ranking corporate officer in the Medical Center administration.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that she had full oversight of the hospital.

Based on interview, record review and policy review, the hospital failed to protect and promote patient's rights when the hospital failed to:
- Provide the hospital's contact information needed to submit a complaint/grievance; (A-0121)
- Follow their policy when they did not contact a patient's legal guardian (a person appointed to take care of and manage the rights of a person who is considered incapable) when the patient sought emergency medical treatment and informed consent was required, for one discharged Patient (#9) of two discharged patients reviewed; (A-0131)
- Investigate the sedation and intubation of one discharged patient with a mental health crisis Patient (#16) of four event reports reviewed; (A-0144)
- Investigate a patient abuse allegation for one discharged Patient (#15) of four event reports reviewed; (A-0144)
- Investigate the handling of a weapon in the Emergency Department (ED) of one discharged psychiatric Patient (#17) of four event reports reviewed; (A-0144)
- Provide a dedicated, secured, ligature (anything which could be used for the purpose of hanging or strangulation) resistant and psychiatric (relating to mental illness) safe patient environment for eight current patients that were located in a locked Behavioral Health Unit (BHU); (A-0144)
- Protect Patient #16 when he was chemically restrained, intubated and placed on a ventilator without a clinical indication; (A-0145)
- Protect Patient #17 when she was subjected to five separate attempts by the physician to place an arterial line (thin, flexible tube placed into an artery); (A-0145)
- Identify the use of sedating medications and intubation as a chemical restraint and failed to document non-restraining methods for behavior management for one Patient (#16) of five discharged patients reviewed with restraints; (A-0160)
- Ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for three discharged Patients (#16, #20, and #21) of five restraint patients reviewed; (A-0175)
- Ensure appropriate violent restraint assessment was completed for one discharged Patient (#16) of two violent restraint patients reviewed; (A-0178) and
- Ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for all provider staff. (A-0206)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Please refer to A-0121, A-0131, A-0144, A-0145, A-0160, A-0175, A-0178 and A-0206







50496

Based on interview and policy review, the facility failed to provide the hospital's contact information needed to submit a complaint/grievance.

This had the potential to inadequately resolve and properly identify grievances and potentially affect all patients.

Findings included:

1. Review of the hospital's document titled, "Complaint Grievance Process," revised 12/2021, showed:
- A patient grievance is defined as a written or verbal concern (when verbal concern about patient care is not resolved at the time of the concern by staff present) by a patient or the patient's representative, regarding the patients care or neglect issues related to the facility's compliance with regulatory agencies.
- The patient will be provided with information on the grievance policy and procedure upon admission to the hospital.
- Each patient is informed of whom to contact to file a grievance.
- The patient may report a grievance verbally or in writing to any hospital/facility staff member.

Review of the hospital's undated document titled, "Patient Right's Handout," showed the contact information to report a grievance to the Department of Health and Senior Services (DHSS). The contact information to report a grievance directly to the hospital was not included.

During an interview on 11/07/24 at 12:00 PM Staff I, Quality and Risk Management Director, stated that the hospital contact information in the Patient Rights information booklet given to patients was missing and should be updated to include that information.

During an interview on 11/18/24 at 11:00 AM Staff J, CNO, stated that she was recently made aware the hospital contact information for filing a grievance directly with the hospital was not included in the Patient's Rights booklet and needed an update to include that information.
















50496

Based on interview, record review and policy review, the hospital failed to follow their policy when they did not contact a patient's legal guardian (a person appointed to take care of and manage the rights of a person who is considered incapable) when the patient sought emergency medical treatment and informed consent was required, for one discharged patient (#9) of two discharged patient records reviewed.

This failure had the potential to affect all patients with a legal guardian who came to the hospital seeking medical treatment.

Findings included:

1. Review of the hospital's policy titled, "Informed Consent," reviewed 08/15/22, showed:
- Informed decision making is a process which occurs continually within the partnership between patient (and surrogate if the patient doesn't have decisional capacity), physician and other healthcare providers and assumes there is shared authority, shared decision making and shared responsibility for health care outcomes.
- A guardian is appointed by the court and legally able to consent on the patient's behalf to necessary medical treatment and to take other actions reasonably required for health and well-being of the patient.
- The provider anticipated as the individual to perform or oversee the procedure or treatment is responsible for informing the patient/decision maker of the alternatives and risks/benefits of the proposed treatment or procedure and the alternatives, answering questions and obtaining the informed decision.
- The nurse validates that the patient has given informed consent by either witnessing the disclosure and consent conversation or reviewing the consent documentation with the patient, assuring the patient has no further questions and validating that the patient has signed the document. The RN documents his/her role as a witness by signing the consent form with the date and time of signature.
- In the event that the court has deemed the patient incapacitated, the court may a appoint a guardian as decision maker. The guardian has the legal authority to make most decisions concerning the patient's healthcare and the legal authority to sign documentation evidencing participation in the decision-making process.
- Once the decision maker, i.e. patient/guardian, are identified, the provider makes the appropriate disclosures, answers questions and obtains the patient's consent or refusal to a proposed plan of care and documents the patient's (or other decision maker's) participation in the decision-making process. It is the provider's responsibility to obtain the patient's consent and document the disclosures on the consent form as appropriate. The nurse or other licensed health care provider may obtain and witness a decision maker's signature on a completed consent form.
- Providers make appropriate disclosures to the guardian, answers guardian's questions and obtains verbal consent or refusal.
- Providers document appropriate disclosures and describes guardian's participation in the decision-making process in the progress notes, clinic record and/or consent form.
- If the proposed treatment requires a completed consent form, the nurse or other health care provider designated by policy may obtain and witness the guardian's signature on a completed form.

Review of the hospital's policy titled, "Decision-Making: Consent Requirements for Medical Treatment/Informed Consent," reviewed 06/2023, showed patients have the right to be informed about the benefits and risks of any treatment/procedure offered to them and to make a voluntary decision (except those under court ordered conservatorship/guardianship, that specifically gives the authority to a guardian) about whether to undergo the treatment/procedure(s). Where patients cannot make their own decisions, respect for persons is upheld by recognizing the decision-making role of an appropriate alternate decision-maker.

Review of the hospital's document titled, "Registration Audit Trail," dated 09/21/24, showed at 3:44 PM, Patient #9's legal guardians contact information was added to the medical record.

Review of Patient #9's medical record dated 09/21/24, showed:
- At 3:03 PM, he was a 34-year-old male who presented to the ED with a complaint of right-hand pain after an altercation at a psychiatric (relating to mental illness) facility.
- At 3:06 PM, he was alert and oriented to person, place and time. His behavior was normal. Additional patient history was obtained from the patient, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and the psychiatric facility.
- At 3:41 PM, Patient #9's Conditions of Admission and Financial Responsibility consent showed he had an altered mental status (AMS, mental functioning ranging from slight confusion to coma). The consent was witnessed by Staff Y, RN and Staff PP, Registration Clerk.
- At 5:58 PM, Patient #9 was discharged from the ED.
- Patient #9's emergency contact information on the face sheet included two public guardians.
- There was no documentation from Staff Y, RN or Staff UU, Physician, regarding contact with Patient #9's guardian to obtain consent for treatment in the medical record.
During a telephone interview on 11/13/24 at 12:30 PM, Staff UU, Physician, stated that he did not know why Patient #9's guardian was not contacted. He contacted the guardian for any patient that was unable to provide consent. He expected communication with the legal guardian to obtain consent for treatment. He expected a team approach to ensure proper consent was obtained from the guardian.

During a telephone interview on 11/07/24 at 9:30 AM, Staff Y, RN, stated that he attempted to determine if a patient had a guardian upon arrival to the ED. He asked the patient if there was a guardian and reviewed any paperwork from a transferring facility. He reviewed the patient's face sheet for emergency contacts. He could not remember if he contacted the guardian for Patient #9. Nine times out of ten he documented contact with the guardian for consent to treat. He was educated on the guardian consent process during hospital orientation.

During an interview on 11/06/24 at 2:38 PM, Staff X, Patient Access Manager, stated that the registration clerk confirmed a patient's mental status with the RN prior to obtaining the consent to treatment. The nurse was made aware the patient had a guardian by the face sheet emergency contacts information.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that guardians must be notified for consent. The nurse was responsible for consent to treatment and the provider was responsible for procedural consent. It was a very difficult to determine which patients had a guardian. She agreed the hospital had an opportunity to improve the guardian notification process.

During a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he expected guardians to be contacted for consent to treatment. It was difficult to identify which patients had a guardian. The hospital needed to evaluate the process for improvement opportunities.

During an interview on 11/06/24 at 1:44 PM, Staff C, Emergency Department (ED) Director, stated that she did not know why Patient #9's consent to treatment showed AMS and the provider showed he was alert and oriented. She expected the nurse to contact the legal guardian for consent to treatment.

Based on observation, interview and policy review, the hospital failed to:
- Investigate the sedation and intubation of one discharged patient with a mental health crisis patient (#16) of four event reports reviewed;
- Investigate a patient abuse allegation for one discharged patient (#15) of four event reports reviewed;
- Investigate the handling of a weapon in the Emergency Department (ED) of one discharged psychiatric patient (#17) of four event reports reviewed; and
- Provide a dedicated, secured, ligature (anything which could be used for the purpose of hanging or strangulation) resistant and psychiatric (relating to mental illness) safe patient environment for eight current patients that were located in a locked Behavioral Health Unit (BHU).

These failed practices placed all patients at increased risk for their safety.

Findings Included:

1. Review of the hospital's policy titled, "Complaint/Grievance Process," reviewed 12/2023, showed consistent with our Mission and Values, St. Joseph Medical Center (SJOMO) supports the assurance of patient rights as mandated by CMS. These rights include the patients right to receive care in a safe setting, be free from all forms of abuse and harassment and be free from restraints and/or seclusion in any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.

Review of the hospital's policy titled, "Administrative Policies and Procedures," reviewed 03/2024, showed patients had the right to respectful treatment, which recognizes and maintains dignity and personal values.

Review of the hospital's policy titled, "Patient Rights and Responsibilities," reviewed 03/2024, showed:
- You or your representative has the right to fair, fast, and objective review of any complaint you have against your health plan, physician or healthcare personnel without fear of reprisal;
- Submit a formal complaint either verbally or written; and
- You will receive a written notice of decision within a reasonable time frame from when the complaint was made known.

Review of the hospital's policy titled, "Restraints: Violent Behavior or Seclusion," revised 09/2022, showed a chemical restraint is a drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom from movement and is not a standard treatment or dosage for the patient's condition. Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.

Although requested the hospital did not provide:
- A policy on a psychiatric safe environment.
- A Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) policy.
- An interview with Staff GGG, Vascular Access Team (VAT) Registered Nurse (RN), who attempted to insert the arterial line for Patient #15, she was out of town.
- An interview with Staff HHH, RN, Patient #15's primary RN, she was on a family and medical leave of absence.

Review of the hospital's document titled, "EVDO360394," dated 07/02/24, showed a patient was brought in by police for suicidal ideation (SI, thoughts of causing one's own death), homicidal ideation (HI, thoughts or attempts to cause another's death) and aggression. The patient eloped from the ED; staff were instructed to not physically engage with the patient. The police were called and the patient was returned to the ED. The patient was sedated and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- On 07/01/24 at 5:18 PM, he was a 44-year-old male who presented to the ED with SI and HI. He reported he drank a half bottle of tequila and a container of bleach with 6,000 milligrams (mg) of Gabapentin (medication used to treat nerve pain or seizures) and 60 mg of Adderall (medication to treat attention deficit/hyperactive disorder [ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors]).
- He was minimally cooperative and remained in an "almost" catatonic (a group of symptoms that usually involve a lack of movement and communication) state. He refused to speak, withdrew from pain in both his arms and legs and was in no acute (sudden onset) distress.
- At 5:45 PM, an order was written for Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) 5 mg intramuscularly (IM, within the muscle) and Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg Intravenous (IV, in the vein).
- At 9:36 PM, Patient #16 suddenly stood up and barged out of the ED pointing at a male staff member and threatened him. Security and police were notified immediately because the patient was a threat to himself and others.
- On 07/01/24 at 10:00 PM, Patient #16 was brought back to the ED by the police. The police were requested to stay with the patient.
- At 10:23 PM, a procedure note showed he was sedated and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety due to his erratic, aggressive and violent behavior.
- On 07/06/24 at 12:20 PM, he was extubated without complication.
- On 07/07/24 at 3:56 PM, Patient #16 left the hospital against medical advice (AMA).

During an interview on 11/14/24 at 9:05 AM, Staff K, Chief Executive Officer (CEO), stated that
she could see the need for an investigation and staff education. She could not recall another psychiatric patient of this severity.

During an interview on 11/07/24 at 8:30 AM, Staff I, Risk Management and Quality Directory, stated that he was unsure how this event was missed and not investigated.

2. Review of the hospital's policy titled, "Arterial Line Placement by Vascular Access Specialist," reviewed 07/25/24, showed:
- Whenever an artery is punctured, there is risk or hemorrhage (excessive bleeding), hematoma (collection of blood below the surface of the skin) formation or limb ischemia (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive).
- Record the procedure, outcome and plan in the progress note.
- Record the time out, indications, procedure, estimated blood loss, outcome, patient tolerance, medications given and the plan in the note.
Review of the hospital's document titled, "EVDO367785," dated 09/06/24, showed a very sick patient required an arterial line (thin, flexible tube placed into an artery). Staff AA, Physician, attempted to place the line, after five attempted needle sticks, he declined assistance from the VAT and stated, "no, she really doesn't need it, I wanted to get the practice." The VAT team attempted two sticks and Staff FFF, Physician, successfully placed the arterial line the same day.
Review of Patient #15's medical record dated 09/04/24 through 09/27/24, showed:
- At 12:16 PM, she was a 55-year-old female who presented to the ED with shortness of breath.
- Her past medical history included a kidney transplant, lung disease, microscopic polyangiitis (MPA, a disease that causes inflammation of blood vessels), obesity (a disorder involving excessive body fat that increases the risk of health problems) and pulmonary hypertension (a condition the affects the blood vessels in your lungs).
- On 09/07/24 at 12:51 PM, a nursing note showed the VAT team was consulted to insert an arterial line. The patient had numerous bruised areas on her right wrist. The line insertion was unsuccessful after two sticks. Staff FFF, Physician, was able to insert the arterial line.
- At 3:06 PM, a procedure note showed, Staff FFF, Physician, placed an arterial line under ultrasound (a test that uses sound waves to create images of structures within the body) guidance.
- There was no procedure note for Staff AA's, Physician, attempts to insert the arterial line.

During an interview on 11/07/24 at 8:30 AM, Staff I, Risk Management and Quality Directory, stated that the Chief Medical Officer (CMO) had a conversation with Staff AA, Physician, in regard to the arterial line insertion event report. No further investigation or staff education was provided. There was an opportunity to perform a more thorough investigation. An argument could be made that the event was abusive to Patient #15. Especially, if Staff AA made the statement in the event report. He stated, "words have power."

During an interview on 11/13/24 at 1:30 PM, Staff VV, CMO, stated that Staff AA, Physician, said he tried "a few sticks" when he attempted to start the arterial line. He did not believe Staff AA stuck the patient as many times as reported in the event report. A provider cannot say "practice," he was a hospital leader. He was receptive to the feedback. Staff VV agreed there was an opportunity for staff education in response to this event.

During an interview on 11/07/24 at 11:40 AM, Staff AA, Physician, stated that the arterial line placement for Patient #15 was "tricky." He initially used a "little poke" to assess the patient's response. She was intubated and he used numbing medication at the site. With the first stick he got blood return, but the blood flow quickly slowed. He pulled the needle back and pushed again and got blood return, but no blood pressure reading. He then tried again and got a good blood return and blood pressure reading. When he tied the line in place he lost the blood pressure. The patient was "very obese." His comments may have been "misunderstood." Perception of some people "may be different." We need to "practice" more on the floors and Intensive Care Unit (ICU, a unit where critically ill patients are cared for). He was brought to the hospital to bring a more "hands on culture." He tried to create a "team culture." He "may have been frustrated, as arterial lines are tricky and challenging." The patient's family was waiting to visit. He wanted to give the patient "a break." He needed to take a "recap" to see how her blood pressures progressed. He had a productive conversation with the CMO, and he welcomed feedback. He was advised to act as a leader.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that staff needed reminders in regard to the chain of command at the moment to prevent patient harm and then complete the event report.

3. Review of the hospital's policy titled, "Public Safety - Contraband and Material Evidence Policy," renewed 01/2023, showed:
- The Public Safety Supervisor should be consulted anytime suspicious items or those that are obviously violations of law are discovered to make sure the disposition is handled properly.
- When Public Safety Officers arrive, personnel will complete a chain-of-custody form.
- The item will be placed in a sealed container and logged into the Public Safety Property Room.
- Public Safety will retain control of the item until properly released to the appropriate law enforcement agency or destroyed.

Review of the hospital's document titled, EVDO369873," dated 10/01/24, showed a gun was found in the belongings of a psychiatric ED patient. Security was called to secure the weapon. The security officer was unable to remove the bullet clip from the gun, he handed the loaded weapon to the patient and asked the patient to remove the clip.

Review of Patient #17's medical record dated 10/01/24, showed:
- At 4:19 PM, he was a 25-year-old male who presented to the ED with a chief complaint of paranoia (excessive suspiciousness without adequate cause), he believed people were chasing him with helicopters.
- A provider note showed Patient #17 was observed to have a holster on his waist band and then he was found to have a loaded gun with an extended magazine in his hoodie.
- A physical assessment showed he had flight of ideas (jumping from one topic to the next, common with mania) and visual and auditory hallucinations (seeing or hearing things which are not there).
- At 9:00 PM, an affidavit (a written statement confirmed by oath, for use as evidence in court) was written, he was a danger to others, was paranoid (excessive suspiciousness without adequate cause) and caried a loaded firearm.
- On 10/02/24 at 1:02 AM, he was transferred to an inpatient psychiatric hospital.

During an interview on 11/07/24 at 8:30 AM, Staff I, Risk Management and Quality Directory, stated that when the "gun event" happened the hospital planned to provide staff education, but it was never done. "He was a big believer in do what we can to prevent further events." The security directory may have had a one-to-one meeting with the security officer involved. The hospital planned to install metal detectors but did not have the security staff to station at the metal detectors.

During an interview on 11/14/24 at 1:08 PM, Staff AAA, Security Manager, stated that he reviewed video of the event, and a lead officer had a peer-to-peer conversation with Staff BBB, Security Officer. He did not follow up with Staff BBB directly.

During an interview on 11/14/24 at 1:21 PM, Staff BBB, Security Officer, stated that he did not receive any official follow-up from the event with Patient #17. The second in command "touched base," reviewed the video and discussed what could have gone better. Education was given over the last "couple of days." The weapon was to be placed in a locked box without manipulation and the police were to be called to secure the weapon.

4. Review of the hospital's policy titled, "Administrative Policies and Procedures," reviewed 03/2024, showed patients had the right to receive care in a safe setting.

Observation on 11/05/24 at 3:45 PM, in the BHU day room, showed four recliners, six tables, three benches, 10 chairs and two end tables that were not psychiatric safe. The dry wall was damaged and peeling.

Observation on 11/05/24 at 3:50 PM, in the BHU hallway, showed one recliner that was not psychiatric safe.

During an interview on 11/05/24 at 3:45 PM, Staff G, BHU Manager, stated that she was aware of the not psychiatric safe furniture, and she recognized the risk of patient harm related to the furniture. She completed two walk throughs in the BHU with her leadership this year, the issue was identified, and correction of the environmental safety concern required a "capital purchase" and needed budget approval.

During an interview on 11/12/24 at 3:25 PM, Staff I, Risk Management and Quality Director, stated that the hospital did not do capital budgets. The CEO spoke with leaders and submitted requests to corporate. There was no waiver for psychiatric safe furniture.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that she had been told the psychiatric furniture was not safe, but they had never had an incident related to the furniture.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, CNO, stated that she reviewed about 13 to 14 event reports every month. She participated in the event review meetings. She needed to "tighten up" the physician review portion of the investigations. The hospital failed to update the event reports with their investigation findings. She needed to work with the Risk Department to coordinate and drive the event review and completion process. Corporate was now involved and rearranged the whole process. All event reports were to be reviewed and follow up accordingly. She wondered if this was a realistic goal. Staff education needed to be provided to "all" staff. She frequently had staff request follow up from their event reports. She planned town hall meetings to provide widespread education to everyone.

During an interview on 11/07/24 at 8:30 AM, Staff I, Risk Management and Quality Director, stated that the Risk Manager reviewed all event reports. A team reviewed event reports every Tuesday. Risk Management was responsible for the event investigations. He included unit leaders to ensure their awareness of events. Why the events were not investigated was a "great question." He needed to expand the event review meeting's agenda with follow-up from previous meetings. He was looking to better "close the loop" with investigations. He needed a more vigorous investigation process.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that the hospital did "lots" of RCAs. A team met every week to review event reports. She expected a more thorough investigation into the events with Patient #15, #16 and #17.

Based on interview, record review and policy review, the hospital failed to ensure patients were free from all forms of abuse, neglect or harassment when Patient #16 was chemically restrained, intubated and placed on a ventilator without a clinical indication. Patient #17 was subjected to five separate attempts by the physician to place an arterial line (thin, flexible tube placed into an artery).

These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

1. Review of the hospital's policy titled, "Patient Rights and Responsibilities," reviewed 03/2024, showed:
- The patient has the right to receive care in a safe setting;
- The patient has the right to be free from all forms of abuse or harassment;
- All patients have the right to be free from physical or mental abuse and corporal punishment;
- All patients have the right to be free from restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff;
- Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time; and
- The patients have the right to be free from seclusion or restraint for behavioral management unless medically necessary to protect physical safety or the safety of others.

Review of the hospital's policy titled, "Reporting Abuse/Neglect Allegations: Child Abuse; Domestic Violent/Spousal Partner; Victims of Assault Battery," reviewed 10/2023, showed:
- The hospital educates staff about how to recognize signs of possible abuse, neglect and about their roles in follow-up;
- Physical abuse is an employee's non-accidental and inappropriate contact with an individual that causes bodily harm. Physical Abuse includes actions that cause bodily harm as a result of an employee directing an individual or person to physically abuse another individual;
- Bodily harm is any injury, damage or impairment to an individual's physical condition or making physical contact of an insulting or provoking nature with an individual; and
- A required reporter is any employee who suspects, witnesses or is informed of an allegation of any one or more of the following: mental abuse, physical abuse, sexual abuse, financial exploitation or neglect.

Review of the hospital's policy titled, "Administrative Policies and Procedures," reviewed 03/2024, showed patients had the right to respectful treatment, which recognizes and maintains dignity and personal values.

Review of the hospital's policy titled, "Restraints: Violent Behavior or Seclusion," revised 09/2022, showed a chemical restraint is a drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom from movement and is not a standard treatment or dosage for the patient's condition. Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.

Review of the hospital's document titled, "EVDO360394," dated 07/02/24, showed a patient was brought in by police for suicidal ideation (SI, thoughts of causing one's own death), homicidal ideation (HI, thoughts or attempts to cause another's death) and aggression. The patient eloped from the ED; staff were instructed to not physically engage with the patient. The police were called. and the patient was returned to the ED. The patient was sedated and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- At 5:18 PM, he was a 44-year-old male who presented to the Emergency Department (ED) with SI and HI\ He reported that he drank a half bottle of tequila and a container of bleach with 6,000 milligrams (mg) of gabapentin (medication used to treat nerve pain or seizures) and 60 mg of Adderall (medication to treat attention deficit/hyperactive disorder [ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors]).
- His past medical history included PTSD, drug and alcohol use, antisocial personality disorder (mental health condition in which a person consistently shows no regard for right and wrong) versus narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors).
- His mother reported the patient had a history of self-harm but frequently lied about ingestions in the past. He went to his "life-coach's" office where the police were notified of his suicide plan.
- He was alert and oriented for police prior to his ED arrival.
- He was minimally cooperative and remained in an "almost" catatonic state (a group of symptoms that usually involve a lack of movement and communication). He refused to speak, withdrew from pain in both his arms and legs and was in no acute (sudden onset) distress.
- At 5:36 PM, his blood alcohol level was 214.
- At 5:45 PM, an order was written for Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) 5 mg intramuscularly (IM, within the muscle) and Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg intravenously (IV, in the vein).
- At 7:56 PM, an in-patient Psychiatry (the study and treatment of mental illness) consult order was placed.
- At 9:36 PM, Patient #16 suddenly stood up and barged out of the ED pointing at a male staff member and threatened him. Security and police were notified immediately.
- At 10:00 PM, Patient #16 was brought back to the ED by the police. The police were requested to stay with the patient.
- At 10:23 PM, a procedure note showed the plan was for sedation and intubation (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety due to his erratic, aggressive and violent behavior.
- Etomidate (A medication that causes a loss of feeling or awareness) and succinylcholine (a muscle relaxant medication) were administered, and the patient was intubated.
- Propofol and Fentanyl (a medication used to treat severe pain and is a high-risk drug for theft and personal use) were administered for intubation sedation.
- A Propofol (medication used to cause decreased level of consciousness and sleepiness during surgical procedures) and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) bolus (large volume) was given after the intubation for agitation.
- Precedex (a sedative that can keep you asleep during surgery or other medical procedures) was administered when Patient #16 fought the ventilator (a machine that supports breathing).
- Just before midnight, Patient #16 was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with a diagnosis of SI, HI, alcohol intoxication, ingestion of toxic substance, suicide attempt and decreased level of consciousness.
- On 07/02/24 at 4:19 AM, a peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) was placed due to poor vascular (relating to or containing blood vessels) access.
- At 10:50 AM, an order was placed for an orogastric (small tubes placed through the mouth and end with the tip in the stomach) and tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube).
- At 9:35 PM, 07/02/24 at 11:29 PM, 07/03/24 at 12:01 PM, 07/04/24 at 2:48 PM, 07/05/24 at 4:46 PM, 07/06/24 at 12:43 PM, progress notes showed the plan was for a psychiatry evaluation after extubation (removal of breathing tube).
- On 07/03/24 at 6:22 AM, an order was placed for a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage).
- At 11:30 AM, the plan was to extubate Patient #16. The Registered Nurse (RN) and Respiratory Therapist (RT) discussed with Staff AA, Physician, that Patient #16's PTSD from war and the July fourth holiday would be difficult and could continue to escalate the patient. The patient was weaned from the sedative medications, became combative, agitated and was not redirectable. The patient was placed back on sedation medications.
- On 07/05/24 at 9:11 AM, a chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed left lower lobe atelectasis (collapse of part or all of a lung).
- On 07/05/24 at 11:04 AM, he was given IV Tylenol (medication that treats minor pains and fever) for a temperature (body temperature normal is 97.8 to 99) of 102.6. He showed signs of withdrawal (symptoms that occur when the intake of a substance such as alcohol or drugs is reduced or stopped) and extubation was deferred at that time.
- On 07/06/24 at 7:21 AM, the sedation was decreased due to low blood pressure.
- At 10:13 AM, a chest x-ray showed worsening left lower lobe atelectasis or pneumonia (infection in the lungs) and development of a small left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart).
- At 12:20 PM, he was extubated without complication.

During an interview on 11/13/24 at 1:30 PM, Staff VV, CMO, stated that the number one tactic for mental health patients was verbal de-escalation and then medications for anxiety, agitation and psychosis (a serious mental illness characterized by defective or lost contact with reality) followed by physical restraints, not chemical restraints. The Security Officer response could have been better, everyone needed to be on the same page. The staff needed education to stay on the same page. He never had to sedate and intubate a patient for a mental health crisis.

During an interview on 11/14/24 at 9:05 AM, Staff K, Chief Executive Officer (CEO) stated that she agreed Patient #16 was chemically restrained and chemical restraints were not "allowed." She could not recall another instance with the severity of Patient #16. She agreed staff needed education and resources for managing mental health patients. The staff were asked to do more with less. Staff were forced to do the best they could with what they had. The hospital needed a well-defined process with focused resources. She wondered who "showed up" for a Code Help (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention), the response staff may not have been the "biggest and/or strongest." She expected documentation if a Code Help was called as well as de-escalation efforts. The sedation and intubation of a patient with a mental health crisis was not done on a regular basis. She intended to use Patient #16's experience as a learning opportunity for staff.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that she agreed Patient #16 was chemically restrained. She believed he was sedated and intubated for alcohol withdrawal. The situation should have been handled differently. There were "lots of opportunities."

During a telephone interview on 11/14/24 at 11:40 AM, Staff YY, Physician, stated that he saw security chasing Patient #16 in the parking lot when he arrived at the hospital. He received report that included the patient history of PTSD, alcohol abuse and SI. He was told the patient received multiple doses of medication, fought staff and eloped. Patient #16 was dangerous enough that if he was brought back to the ED the plan was to sedate and intubate. Three police officers and a security officer brought him back to the ED he was not actively fighting, was agitated, on edge and poised to run. He explained the sedation and intubation to Patient #16, and he agreed. He believed other options had been attempted, he was given medications and became "explosive." He did not agree Patient #16 was chemically restrained because the patient consented and there were no other good options. He could have given more medications and waited for the medications to "kick in." Patient #16 already exhibited explosive behaviors after his catatonia catatonia (a group of symptoms that usually involve a lack of movement and communication, and can also include agitation, confusion, and restlessness). The nursing staff were afraid of him. He was concerned that security staff may not be available if Patient #16 exploded again.

During a telephone interview on 11/13/24 at 1:20 PM, Staff CC, Physician, stated that it was not common practice to intubate for a mental health crisis. The decision to sedate and intubate for a mental health crisis was not something to rush. A provider should try to avoid sedation and intubation for a mental health crisis. It was a judgement call. She expected less extreme treatment options were tried first.

During an interview on 11/13/24 at 11:40 AM, Staff AA, Physician, stated that he tried to wean the sedation of Patient #16 after two to three days and the patient became agitated. The nurses were a "little bit" nervous about extubating Patient #16 on the Fourth of July holiday because of the patient's history of PTSD and war deployment. The nurses wanted to wait unit the next day for provider availability. He was not surprised by the development of pneumonia; the patient may have aspirated (inhalation of foreign material into the lungs).

During an interview on 11/07/24 at 8:30 AM, and a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he was not aware Patient #16 was sedated and intubated without a medical indication. Sedation and intubation for a mental health crisis should not be a common practice, Patient #16 was a "one off." The hospital needed to increase their resources and staff education. He expected the lowest form of restraints. He agreed staff needed education regarding the definition of a chemical restraint. There were opportunities in the ED in regard to managing psychiatric (relating to mental illness) patients. He wondered if the hospital even addressed Patient #16's chief complaint.

During an interview on 11/13/24 at 12:45 PM, Staff BB, Mental Health (MH) Nurse Practitioner, (NP, a nurse with advanced clinical education and training) stated that she had never seen a patient sedated and intubated for a mental health crisis. She expected to see levels of interventions prior to sedation and intubation. The patient had a suicide attempt, did not receive a mental health evaluation and was allowed to discharge against medical advice.

During a telephone interview on 11/14/24 at 11:55 AM, Staff ZZ, MHNP, stated that she did not recall another instance of sedation and intubation for a mental health crisis. She agreed Patient #16 was chemically restrained if the sedation and intubation were done intentionally for a mental health crisis.

During an interview on 11/14/24 at 12:00 PM, Staff C, ED/ICU Director, stated that she did not expect staff to document de-escalation efforts. The level of fear may have led to the sedation and intubation of Patient #16 as he was military trained. Everyone was scared of him. Staff should have tried other options. Medication should have been given with his behavior escalation.

During a telephone interview on 11/13/24 at 2:02 PM, Staff FF, RN, stated that the decision to sedate and intubate a patient for a mental health crisis was at the providers discretion. Patient #16 was calm and sleepy until he "snapped" and eloped. She instructed staff not to physically intervene. The police were called, and the patient was returned to the ED. It was not a common practice to sedate and intubate for a mental health crisis. Most patients could be redirected and de-escalated. She expected to see documentation of medications given and notes to describe the patient's behavior to indicate the need for sedation and intubation.

During a telephone interview on 11/14/24 at 10:07 AM, Staff WW, RN, stated that Patient #16 presented to the ED with three police officers. He had no expression, a flat affect (observable facial, vocal or gestural behaviors that are an expression of feelings). He did not fight when he was hand cuffed. She saw no aggression from Patient #16.

During an interview on 11/14/24 at 11:32 AM, Staff XX, RN, stated that she agreed Patient #16 was chemically restrained, it was inappropriate, sedation and intubation was the "very-very last intervention." She did not remember another situation where a patient was sedated and intubated for a mental health crisis. The usual management of a mental health patient was to use the least extreme intervention first. Sedation and intubation of a mental health crisis patient was not "very appropriate." Patient #16 needed a mental health evaluation and additional medications. She expected documentation of other interventions and the patient behaviors in the medical record.

During an interview on 11/14/24 at 1:08 PM, Staff AAA, Security Manager, stated that staff were heightened and afraid of Patient #16. There was not enough support staff. He felt the police should stay if the patient was dangerous. The police were not routinely available.

2. Review of the hospital's policy titled, "Arterial Line Placement by Vascular Access Specialist," reviewed 07/25/24, showed:
- The goal of arterial line placement is to provide a means for monitoring a patient's blood pressure moment-to-moment and to have access to the arterial blood supply for laboratory analysis;
- Whenever an artery is punctured, there is risk or hemorrhage (excessive bleeding), hematoma (collection of blood below the surface of the skin) formation or limb ischemia (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive); and
- Documentation in the electronic medical record of the pretreatment evaluation, record the time out, indications, procedure, estimated blood loss, the outcome, patient tolerance, medications given and the plan in the note, as well as any self-care instructions.

Although requested the hospital did not provide:
- An interview with Staff GGG, Vascular Access Team (VAT) Registered Nurse (RN), who attempted to insert the arterial line for Patient #15, she was out of town.
- An interview with Staff HHH, RN, Patient #15's primary RN, she was on a family and medical leave of absence.

Review of the hospital's document titled, "EVDO367785," dated 09/06/24, showed a very sick patient required an arterial line. Staff AA, Physician, attempted to place the line, after five sticks he declined assistance from the VAT and stated, "no, she really doesn't need it, I wanted to get the practice." The VAT team attempted two sticks and Staff FFF, Physician, successfully placed the arterial line the same day.

Review of Patient #15's medical record dated 09/04/24 through 09/27/24, showed:
- At 12:16 PM, she was a 55-year-old female who presented to the ED with shortness of breath.
- Her past medical history included a kidney transplant, lung disease, microscopic polyangiitis (MPA, a disease that causes inflammation of blood vessels), obesity (a disorder involving excessive body fat that increases the risk of health problems) and pulmonary hypertension (a condition the affects the blood vessels in your lungs).
- On 09/07/24 at 12:51 PM, a nursing note showed the VAT team was consulted to insert an arterial line. The patient had numerous bruised areas on her right wrist. The line insertion was unsuccessful after two sticks. Staff FFF, Physician, was able to insert the arterial line.
- At 3:06 PM, a procedure note showed, Staff FFF, Physician, placed an arterial line under ultrasound (a test that uses sound waves to create images of structures within the body) guidance.
- There was no procedure note for Staff AA's, Physician, attempts to insert the arterial line.

During an interview on 11/13/24 at 1:30 PM, Staff VV, CMO, stated that a provider could not say "practice" on a patient. He agreed the hospital had opportunities for staff education for abuse.

During an interview on 11/13/24 at 11:40 AM, Staff AA, Physician, stated that "maybe the staff member who filed the event report misunderstood his comments." The perception of some people may be "different." He stated that "we needed to practice more on the floor and Intensive Care Unit (ICU, a unit where critically ill patients are cared for)." He maybe got frustrated, arterial lines were tricky and challenging. He needed to take a "break and recap to see how her blood pressure progressed." The Chief Medical Officer (CMO) advised him to act as a leader.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO stated that it was hard to say how many "sticks" were appropriate with an arterial line insertion attempt. The comments made by Staff AA, Physician, did not fit into the hospital's culture. The time and place of his comments was not okay. She recognized Staff AA's passion may not be well received.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, CNO, stated that she was aware of Staff AA, Physician's event with the arterial line. All Staff needed education regarding abuse to include the chain of command escalation, interruption and reporting of abuse.

During an interview on 11/14/24 at 12:00 PM, Staff C, ED/ICU Director, stated that she was not surprised by Staff AA's, Physician, comments. He was referred to the CMO and she spoke with the nurse. She believed the nurse may have exaggerated the number of sticks. She expected Staff AA to write a procedure note for any procedure attempt.

During a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he needed to take a closer look at this event. To substantiate abuse, he needed to circle back to staff for more information. Education needed to include "see something, do something."

Based on interview, policy review and record review the hospital failed to identify the use of sedating medications and intubation as a chemical restraint and failed to document non-restraining methods for behavior management for one patient (#16) of five discharged patient records reviewed with restraints.

Findings included:

1. Review of the hospital's policy titled, "Restraints: Violent Behavior or Seclusion," revised 09/2022, showed:
- A chemical restraint is a drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom from movement and is not a standard treatment or dosage for the patient's condition.
- Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.
- The type or technique of restraint used must be the least restrictive intervention that will be effective to protect the patient, a staff member or others from harm.
- Prior to use, risks associated with use of restraint/seclusion are determined to outweigh risks of not using restraints/seclusion. Restraining therapies should be used only when clinically appropriate, when the risk of untoward treatment interference by the patient outweighs the physical, psychological and ethical risks of their use.
- Alternatives to the use of restraints include reorientation to person, place and time; redirection of the patient's focus; relief of pain; meeting identified physical needs such as hunger, toileting, sleep, thirst and exercise according to individual routine rather than facility routine; psychosocial interventions including meeting lifelong habits and patterns of daily activity; provide a structured, consistent, quiet environment; more frequent supervision, avoiding unnecessary arousal; evaluation to identify/manage a problem that would obviate the need for restraints i.e. agitation's underlying cause may be pain, hypoxemia, hypercapnia or other organic conditions; active listening and being attentive; modification of care, i.e. removal of a dressing or device; consultation with physician; treatment plan review, care conference; companionship and supervision including the use of volunteers, family, friends, etc.; physical and diversionary activity such as exercise, television, music, videos; environmental approaches; alarms, good lighting, reduced glare, mattress on floor to reduce falls; verbal de-escalation and clear, concise verbal instructions, allow choice.
- The use of restraint is not solely based on the history of restraint/seclusion use nor on the presence of a dangerous behavior.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- At 5:18 PM, he was a 44-year-old male who presented to the Emergency Department (ED) with suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death). He reported that he drank a half bottle of tequila and a container of bleach with 6,000 milligrams (mg) of Gabapentin (medication used to treat nerve pain or seizures) and 60 mg of Adderall (medication to treat attention deficit/hyperactive disorder [ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors]).
- His past medical history included Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), drug and alcohol use, antisocial personality disorder (mental health condition in which a person consistently shows no regard for right and wrong) versus narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors).
- He was minimally cooperative and remained in an "almost" catatonic state (a group of symptoms that usually involve a lack of movement and communication). He refused to speak, withdrew from pain in both his arms and legs and was in no acute (sudden onset) distress.
- At 5:36 PM, his blood alcohol level was 214.
- At 5:45 PM, an order was written for Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) 5 mg intramuscularly (IM, within the muscle) and Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg Intravenous (IV, in the vein).
- At 9:36 PM, Patient #16 suddenly stood up and barged out of the ED pointing at a male staff member and threatened him. Security and police were notified immediately because the patient was a threat to himself and others.
- At 10:00 PM, Patient #16 was brought back to the ED by the police. The police were requested to stay with the patient.
- At 10:23 PM, a procedure note showed he was sedated and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety due to his erratic, aggressive and violent behavior.
- Etomidate (a medication that causes a loss of feeling or awareness) and succinylcholine (a muscle relaxant medication) were administered, and the patient was intubated.
- Propofol (medication used to cause decreased level of consciousness and sleepiness during surgical procedures) and fentanyl (a medication used to treat severe pain and is a high-risk drug for theft and personal use) were administered for intubation sedation.
- A Propofol and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) bolus (large volume) was given after the intubation for agitation.
- Precedex (a sedative that can keep you asleep during surgery or other medical procedures) was administered when Patient #16 fought the ventilator (a machine that supports breathing).
- On 07/02/24 at 4:19 AM, a peripherally inserted central catheter (PICC line, a flexible tube inserted into a arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) was placed due to poor vascular (relating to or containing blood vessels) access.
- At 8:05 AM, his drug screen was positive for amphetamines (a class of psychoactive drugs that stimulates and speeds up the body's system) benzodiazepines (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia) and marijuana.
- At 10:50 AM, an order was placed for an orogastric (small tubes placed through the mouth and end with the tip in the stomach) tube and feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube).
- On 07/03/24 at 6:22 AM, an order was placed for a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage).
- At 11:30 AM, the plan was to extubate Patient #16. The Registered Nurse (RN) and Respiratory Therapist (RT) discussed with Staff AA, Physician, that Patient #16's PTSD from war and the July fourth holiday would be difficult and could continue to escalate the patient. The patient was weaned from the sedative medications, became combative, agitated and was not redirectable. The patient was placed back on sedation medications and remained intubated.
- On 07/05/24 at 9:11 AM, a chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed left lower lobe atelectasis (collapse of part or all of a lung).
- On 07/06/24 at 7:21 AM, the sedation was decreased due to low blood pressure.
- At 10:13 AM, a chest x-ray showed worsening left lower lobe atelectasis or pneumonia (infection in the lungs) and development of a small left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart).
- At 12:20 PM, he was extubated without complication.

During a telephone interview on 11/14/24 at 11:40 AM, Staff YY, Physician, stated that he saw security chasing Patient #16 in the parking lot when he arrived at work. He received report, the patient had a history of PTSD, alcohol use, and SI. He was told the patient received multiple doses of medications, fought staff and eloped (when a patient makes an intentional, unauthorized departure from a medical facility). The patient was dangerous, and the plan was to sedate and intubate him when he returned to the ED. Three police officers and a security officer brought him back to the ED, he was not actively fighting, he was agitated, on edge and poised to run. He educated the patient on sedation and intubation and the patient agreed. A psychiatry consult was not done in the ED for Patient #16, he was never in an appropriate condition for the consult. He did not agree sedation and intubation were chemical restraints. The patient consented and there were no other "good options." He questioned if he could have prescribed more medications, the patient had already displayed explosive behavior. The nurses were afraid of him. He was concerned they may not have the security staff needed if he became explosive again.

During an interview on 11/13/24 at 1:30 PM, Staff VV, Chief Medical Officer (CMO), stated that psychiatric patients could be very dangerous. The number one tactic for a mental health crisis was verbal de-escalation followed by medications followed by physical restraints. There was no documentation of the patient's volatility. The hospital recently identified a telehealth psychiatric order must be written as tele-psych for the provider to receive the consult. He expected tele-psych to respond when called. He identified security response as an opportunity, "everyone needed to be on the same page." There was a need for education to ensure everyone was on the same page. He had never sedated and intubated a patient for a mental health crisis. Alcohol withdrawal was an indication for sedation and intubation in some cases. Delirium tremors (DT, life threatening form of alcohol withdrawal) began within four to five days of alcohol abstinence. DTs did not last "too long."

During a telephone interview on 11/07/24 at 1:20 PM, Staff CC, Physician, stated that she had seen patients intubated for a mental health crisis, there was an increased mortality rate with severe withdrawal. It was not common to rush to sedation and intubation. It came down to a judgement call. She expected the least extreme treatment options to be tried first. Patient #16 was very strong and well developed.

During an interview on 11/07/24 at 11:40 AM, Staff AA, Physician, stated that a patient had to have extremely bad withdrawal to indicate sedation and intubation. Providers used "clinical judgement" to choose lesser extreme strategies depending on the patient's risk of harm to self and others. He attempted to wean Patient #16 from the ventilator after two to three days. The patient showed symptoms of withdrawal and he waited three to four days before extubating him. Staff were a "little bit" nervous about extubating him over the July fourth holiday due to his history of PTSD and wanted to wait until there was more provider availability. He could not remember if violent restraints were ever attempted with Patient #16. He did not have close interaction with psychiatry services, he was unsure of psychiatry availability for consults. He expected a psychiatry consult was placed within the "first minute" for patients similar to Patient #16. He was surprised Patient #16 developed pneumonia; the patient could have aspirated (inhalation of foreign material into the lungs).

During an interview on 11/14/24 at 9:05 AM, Staff K, Chief Executive Officer (CEO), stated that she agreed sedation and intubation for a mental health crisis was a chemical restraint and not an appropriate plan of care. She intended to use this event as a learning opportunity. She agreed the hospital had an opportunity to provide education, resources and improved documentation for mental health patients. The staff were asked to do more with less. "We were forced to do the best we could with what we had." We needed a well-defined process with focused resources. Opportunities included who showed up to a "code help" may not always be the biggest or strongest staff members. She expected to see documentation in the medical record if a code strong was called as well as de-escalation efforts. Staff ZZ, MHNP, could have offered suggestions to the ED but she was not legally obligated because she was credentialed for patients 55 years old or older. The police department was available if needed.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that she agreed the sedation and intubation of Patient #16 was a chemical restraint. She believed he was intubated for alcohol withdrawal with DT's, not a mental health crisis. The event should have been handled differently, there were "lots of opportunities."

During an interview on 11/14/24 at 12:00 PM, Staff C, ED/ICU Director, stated that she agreed Patient #16 was chemically restrained. She did not expect staff to document de-escalation efforts. She expected this event would improve medical record documentation. The staff's level of fear may have led to Patient #16's sedation and intubation, he was military trained. Other options should have been tried. She did not know why a psychiatry consult was not done after he was extubated in the ICU, as tele-psych was not an emergent consult. The psychiatry consult should have been at the staff's forethought, but that did not happen. "Everyone was scared of him." They should have administered medications and attempted restraints when he escalated.

During an interview on 11/07/24 at 8:30 AM, Staff I, Risk Management and Quality Director, stated that he was not aware Patient #16 was sedated and intubated without a medical indication. He identified an opportunity to increase resources and staff education. He expected the lowest form of restraints. "They missed a couple of hurdles with Patient #16."

During an interview on 11/07/24 at 12:45 PM, Staff BB, Mental Health (MH) Nurse Practitioner (NP, a nurse with advanced clinical education and training), stated that she expected to see levels of interventions before a patient was sedated and intubated for mental health reasons. Veterans with combat deployment required different management for safety. She did not know if he was at risk to self or others, no behaviors were documented. The hospital had a telehealth psychiatry contract for after hours and weekend psychiatry consults. Telehealth was only useful if the patient was cooperative. She would have liked to see a psychiatric evaluation completed for Patient #16.

During a telephone interview on 11/14/24 at 11:55 AM, Staff ZZ, MHNP, stated that she did not recall her involvement with Patient #16. She was not on-call for the ED. The hospital had a contracted psychiatry service for ED consults. Patients under 55 years-old admitted to the hospital over the weekend in need of a psychiatry consult waited until Monday to see psychiatry. She agreed Patient #16 was chemically restrained if he was intentionally sedated and intubated without a medical indication.

During a telephone interview on 11/07/24 at 2:02 PM, Staff FF, RN, stated that the decision to sedate and intubate a mental health patient was at the providers discretion. Patient #16 was medicated with a dose of Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder [manic depression]), which was not effective. The provider wanted to give stronger medication without a concern for the patient's airway. Patient #16 initially appeared calm and sleepy until he "snapped" and eloped. The police were able to quickly locate him. It was not a common practice to sedate and intubate for a mental health crisis. Most patients could be de-escalated and redirected. This was not "normal by any means." She expected to see documentation of the patient's behaviors to indicate a need for sedation and intubation.

During a telephone interview on 11/14/24 at 11:32 AM, Staff XX, RN, stated that she did not remember another time a patient was sedated and intubated for a mental health crisis. It was "unusual management." She used the least severe intervention first. Sedation and intubation were not "very appropriate." When a patient returned to the ED after an elopement the ED process "started over." Patient #16 definitely needed a psychiatric consult and other medication administrations. She agreed sedation and intubation for a mental health crisis was a chemical restraint and was the "very-very last intervention." She would have documented other interventions attempted and the patient's behaviors in the medical record.

During an interview on 11/14/24 at 10:07 AM, Staff WW, RN, stated that she was the triage (process of determining the priority of a patient's treatment based on the severity of their condition) nurse when the police brought Patient #16 in for evaluation. He came in with three police officers, had no expression and was not fighting the handcuffs. She did not see any aggression.

During an interview on 11/14/24 at 11:03 AM, Staff F, RN, stated that he agreed the sedation and intubation of Patient #16 was a chemical restraint.

Based on interview, record review and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for three discharged patients (#16, #20, and #21) of five restraint patient records reviewed.

This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings Included:

1. Review of the hospital's policy titled, "Use of Restraints," dated 02/25/22, defines the use of a physical restraint for violent or self-destructive behavior and non-violent behavior and requires observations, assessments and care completed as often as needed but at least every 15 minutes for violent restraints and every two hours for non-violent restraints. Patients are assessed by an RN immediately after restraints are initiated to assure safe application of the restraint.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- On 07/02/24 at 12:00 AM, 07/03/24 at 12:00 AM and 5:53 AM, 07/04/24 at 8:56 PM, 07/05/24 at 8:00 PM, 07/06/24 at 7:22 PM and 07/07/24 at 9:17 AM orders were placed for soft restraints to both arms.
- On 07/04/24 at 2:37 AM, a restraint assessment and cares were completed. A time lapse of two days, two hours and 37 minutes after the restraints were placed.
- At 10:00 AM and 07/07/24 at 7:00 AM, a restraint assessment and cares were completed. A time lapse of two days, 21 hours and 30 minutes between restraint assessments.

Review of Patient #20's medical record dated 09/12/24, showed:
- On 09/12/24 at 12:34 PM, an order was placed for four point locked violent restraints.
- Assessments were completed every 15 minutes through 1:30 PM. No further restraint assessment or cares were completed.
- At 3:40 PM, the violent restraints were discontinued. Patient #20 remained in violent restraints for two hours and 10 minutes without an assessment or cares.

Review of Patient #21's medical record dated 09/05/24, showed:
- At 4:14 PM, an order was placed for soft restraints to both legs.
- At 4:45 PM, a restraint assessment and cares were completed. A time lapse of 36 minutes after the restraints were applied.
- No further restraint assessments or cares were completed.
- At 7:20 PM, the restraints were discontinued. Patient #21 remained in non-violent restraints for two hours and 35 minutes without a restraint assessment or cares.

During an interview on 11/18/24 at 12:00 PM, Staff I, Quality Director, stated that he expected staff to follow the restraint policy.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that she expected staff to follow the restraint policy.

During an interview on 11/18/24 at 10:59 AM, Staff J, CNO, stated that she expected staff to follow the restraint policy.


50496

Based on interview, record review and policy review, the hospital failed to follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on one discharged patient (#16) of two violent restrained discharged patients reviewed.

Findings included:

1. Review of the hospital's policy titled, "Use of Restraints," reviewed 02/25/22, showed a face-to-face assessment by a Licensed Independent Practitioner (LIP)/physician or RN with demonstrated competence must be done within one hour of administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others. At the time of the face-to-face assessment, the LIP/physician/RN will work with staff and patient to identify ways to help the patient regain control, evaluate the patient's immediate situation, evaluate the patient's reaction to the intervention, evaluate the patient's medical and behavioral condition, evaluate the need to continue or terminate the restraint or seclusion and revise the plan of care, treatment and services as needed.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- At 5:18 PM, he was a 44-year-old male who presented to the Emergency Department (ED) with suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death).
- His past medical history included Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), drug and alcohol use, antisocial personality disorder (mental health condition in which a person consistently shows no regard for right and wrong) versus narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors).
- At 5:45 PM, an order was written for Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) 5 mg intramuscularly (IM, within the muscle) and Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg Intravenous (IV, in the vein).
- There was no documented face-to-face.
- At 9:36 PM, Patient #16 suddenly stood up and barged out of the ED pointing at a male staff member and threatened him. Security and police were notified immediately because the patient was a threat to himself and others.
- At 10:23 PM, a procedure note showed he was sedated and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety due to his erratic, aggressive and violent behavior.
- Etomidate (a medication that causes a loss of feeling or awareness) and succinylcholine (a muscle relaxant medication) were administered, and the patient was intubated.
- Propofol (medication used to cause decreased level of consciousness and sleepiness during surgical procedures) and fentanyl (a medication used to treat severe pain and is a high-risk drug for theft and personal use) were administered for intubation sedation.
- A Propofol and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) bolus (large volume) was given after the intubation for agitation.
- Precedex (a sedative that can keep you asleep during surgery or other medical procedures) was administered when Patient #16 fought the ventilator (a machine that supports breathing).
- There was no documented face-to-face.

During an interview on 11/14/24 at 9:05 AM, Staff K, Chief Executive Officer (CEO), stated that she expected staff to follow the restraint policy.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that she expected staff to follow the restraint policy.

During a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he expected staff to follow the restraint policy.

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for all provider staff.

This failure had the potential to result in serious injury or death to patients who required restraints in the hospital.

Findings included:

1. Review of the hospital's policy titled, "Use of Restraints," reviewed 02/25/22, showed:
- The purpose of the policy was to define staff training requirements related to safe processes.
- Physicians and other Licensed Independent Providers (LIPs) authorized to order restraints will have a working knowledge of this policy on the use of restraints.
- Restraint training content includes first aid. Staff will be trained and able to demonstrate competency in first aid techniques for patients in restraints who are in distress or injured.

Although requested, the hospital failed to provide training requirements and completion logs for physicians and LIPs for restraint/seclusion first aid.

Review of the hospital's restraint log showed violent and/or non-violent restraints were utilized on patients 99 times for the previous six months.

During a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that first aid training was not part of the provider curriculum.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that she was not aware first aid restraint training was required for providers.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, CNO, stated that she was not aware first aid restraint training was required for providers.

Based on observation, record review, interview and policy review, the hospital failed to provide repositioning for one patient (#10) of one patient reviewed.

This failure had the potential to lead to poor outcomes, increased risk of infection, impaired skin integrity and overall increased risk of health status deterioration for every patient admitted to the hospital.

Findings included:

1. Review of the hospital's policy titled, "Skin Integrity Policy," revised 04/17/23, showed:
- The nursing team will position the patient to ensure skin integrity is maintained by repositioning the patient as frequently as the patient can tolerate, minimally every two hours;
- Document all prevention actions in the medical record; and
- For patients with Braden Scale scores 15-18, they are deemed as a mild risk.
- The pressure ulcer prevention actions are to turn and or reposition the patient every one to two hours.

Review of Patient #10's medical record dated 10/13/23 through 10/25/23, showed:
- On 10/13/23 at 11:25 PM, she was an 88-year-old woman with diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) type two. She was admitted to the medical surgical unit after a fall at home resulting in a left hip fracture.
- At 9:20 PM, the patient's sacral area showed redness. She was bedfast and had limited mobility.
- On 10/14/23 through 10/24/23, her Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers) score was 17 to 18.
- On 10/16/23 at 10:00 AM, she was up in a chair through 8:20 PM, when she was placed in a supine position. She remained in a chair for 10 hours and 20 minutes.
- On 10/20/23 at 2:00 AM, she was positioned on her right side with pillow support through 8:00 AM, when she ambulated to a chair. She remained on her right side for six hours.
- At 4:00 PM, she was positioned on her right side with pillow support through 8:00 PM, when she was repositioned to a semi-fowlers position. She remained on her right side for four hours.
- On 10/21/23 at 4:00 PM, she was provided pillow support through 9:00 PM, when she was repositioned on her left side. She remained in the same position with pillow support for five hours.
- On 10/22/23 at 7:01 AM, she was sitting through 12:00 PM, when she was repositioned to a semi-fowlers position. She remained in a sitting position for four hours and 59 minutes.

During an interview on 11/14/24 at 10:00 AM, Staff T, Nurse Manager, stated there were opportunities for patient repositioning and documentation.

During an interview on 11/14/24 at 12:45 PM, Staff OO, RN, stated that she remembered caring for Patient #10. Before the patient's hip surgery, she was not able to turn onto her hip or ambulate. She turned her every two to three hours unless the patient refused. She cushioned the patient's buttocks area with pillows to help with off-loading some of the pressure from the sacral region.

Based on observation, interview, and policy review, the hospital failed to:
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for 11 patients (#4, #5, #11, #12, #13, #14, #25, #26, #27, #28 and #29) of 19 patients observed; (A-0749)
- Label intravenous (IV, in the vein) antibiotic medications prepared by staff on the unit for four patients (#2, #14, #25 and #28) of six patients observed; (A-0749)
- Prepare a clean work surface, sanitize equipment and ensure the use of clean/sterile supplies prior to performing patient care for nine patients (#2, #6, #7, #11, #12, #14, #25, #26, and #27) of 19 patients observed; (A-0749)
- Remove expired food, label food with expiration dates, maintain the refrigerator temperature log, and maintain a cleaning schedule in the main kitchen; (A-0749)
- Remove expired supplies from the crash cart (mobile cart which contains emergency medical supplies and medication) on two units of 12 units observed; (A-0749)
- Remove tape adhesive residue from multiple surfaces in patient care areas to create a cleanable surface on 16 units of 16 units observed; (A-0749) and
- Follow their Infection Prevention Plan to maintain a sanitary environment. (A-0749).

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship.

Please refer to A-0749.


48359




50496

Based on observation, interview, and policy review, the hospital failed to:
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for 11 patients (#4, #5, #11, #12, #13, #14, #25, #26, #27, #28 and #29) of 19 patients observed;
- Label intravenous (IV, in the vein) antibiotic medications prepared by staff on the unit for four patients (#2, #14, #25 and #28) of six patients observed;
- Prepare a clean work surface, sanitize equipment and ensure the use of clean/sterile (completely clean and free from germs) supplies prior to performing patient care for nine patients (#2, #6, #7, #11, #12, #14, #25, #26 and #27) of 19 patients observed;
- Remove expired food, label food with expiration dates, maintain the refrigerator temperature log, and maintain a cleaning schedule in the main kitchen; (A-0749)
- Remove expired supplies from the crash carts (mobile cart which contains emergency medical supplies and medications) on two units of 12 units observed;
- Remove tape adhesive residue from surfaces in patient care areas to create a cleanable surface on 16 units of 16 units observed; and
- Follow nationally recognized standards to maintain a sanitary environment.

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

1. Review of the hospital's policy titled, "Infection Control, HH," reviewed 01/13/22, showed HH should be performed:
- When hands or gloves are visibly dirty or contaminated with material or are visibly soiled with blood or other body fluids;
- Before eating and after using a restroom;
- If exposed to bacteria;
- Before having direct contact with patients;
- After contact with a patient's intact skin;
- After contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings;
- If moving from a contaminated-body site to a clean-body site;
- After contact with inanimate objects (including medical equipment) in the patient rooms; and
- After removing gloves.

Review of the hospital's document titled, "HH Compliance," dated 11/14/24, showed HH compliance ranged from 96 percent to 98 percent for the last three quarters.

Observation on 11/05/24 at 3:13 PM, showed Staff M, Registered Nurse (RN), failed to perform HH when she entered Patient #4's room and when moving from a dirty area to a clean area.

Observation on 11/05/24 at 3:35 PM, showed Staff N, RN, failed to perform HH when she entered Patient #5's room.

Observation on 11/06/24 at 9:50 AM, showed Staff Q, Licensed Practical Nurse (LPN) failed to perform HH and glove changes on three separate occasions when moving from a dirty area to a clean area when she provided care to Patient #11.

Observation on 11/06/24 at 10:28 AM, showed Staff R, LPN, failed to perform HH after removing a wound dressing and before donning clean gloves. She failed to perform HH between glove changes when she provided care to Patient #12.

Observation on 11/06/24 at 11:10 AM, showed Staff U, RN, failed to perform HH and glove changes on three separate occasions when moving from a dirty area to a clean area when she provided care to Patient #13.

Observation on 11/06/24 at 11:12 AM, showed Staff S, RN, failed to perform HH when she exited Patient #12's room.

Observation on 11/06/24 at 2:00 PM, showed Staff R, LPN, failed to perform HH before donning gloves and after removing a dressing from Patient #14's wounds. She failed to perform HH and glove changes when she picked up an IV tubing from the floor. She failed to discard and replace the IV tubing prior to use for Patient #14.

Observation on 11/13/24 at 10:15 AM, showed Staff N, RN, failed to perform HH before and after glove changes when she provided care to Patient #25.

Observation on 11/13/24 at 11:21 AM, showed Staff KK, Physical Therapist (PT), exited Patient #28's room wearing gloves and used an alcohol-based hand sanitizer on her gloved hands.

Observation on 11/13/24 at 11:24 AM, showed Staff LL, Patient Care Technician (PCT), failed to perform HH when she entered Patient #26 room. She failed to perform HH and glove changes after she performed a blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) test and wrote on the dry erase board in Patient #26's room.

Observation on 11/13/24 at 11:31 AM, showed Staff LL, PCT, failed to remove gloves and perform HH after she performed a blood glucose test and wrote on the dry erase board in Patient #27's room.

Observation on 11/13/24 at 1:31 PM, showed Staff W, RN, failed to perform HH when she entered Patient #29's room. She performed a blood glucose test and left the room wearing the gloves used to perform the blood sample. She failed to perform HH between glove changes when she cleaned the equipment.

Observation on 11/13/24 at 2:05 PM, showed Staff CCC, RN failed to perform HH and glove changes between wounds when she applied topical medication to four wounds on the left leg and three wounds on the right leg with the same gloved finger for Patient #14.

During an interview on 11/14/24 at 9:51 AM, Staff K, Chief Executive Officer (CEO), stated that she expected staff to follow the HH policy. Staff were to change gloves and perform HH when moving from a dirty area to a clean area. She did not expect staff to apply topical medication to multiple open wounds with the same gloved finger. Staff should perform HH and glove changes between wounds and use a clean cotton tipped applicator or tongue depressor for each wound. HH should be performed with each glove change and when entering and exiting rooms.

During an interview on 11/14/24 at 9:40 AM, Staff J, Chief Nursing Officer (CNO), stated that HH was never 100 percent successful on the audits, and they continuously educated staff. They did not do direct bedside observations for HH and glove changes but did watch from the unit for HH when entering and exiting patient rooms. She expected staff to perform HH with glove changes, when going from dirty to clean, with patient contact and entering and exiting rooms.

During an interview on 11/14/24 at 2:17 PM, Staff L, Infection Preventionist, stated that staff were to utilize the five moments of HH. She did observations on rounds but did not often observe at the bedside.

2. Review of the hospital's policy titled, "IV infusion Pumps, Tubings and Filters," reviewed 08/17/22, showed the IV bags and tubings should have labels documenting the time the IV bag and tubing were hung.

Observation on 11/13/24 at 10:15 AM, showed Staff N, RN, failed to label Patient #25's IV medication bag and tubing.

Observation on 11/13/24 at 1:06 PM, showed Patient #2 had an unlabeled IV medication bag.

Observation on 11/13/24 at 1:31 PM, showed Patient #28 had an unlabeled IV medication bag.

Observation on 11/13/24 at 2:05 PM showed Patient #14 had an unlabeled IV medication bag.

During an interview on 11/18/24 at 11:00 AM, Staff J, CNO, stated that staff were to use the pharmacy labels on the IV medications bags.

During an interview on 11/18/24 at 12:07 PM, Staff I, Risk Management and Quality Director, stated that the pharmacy label was to be used for IV medications prepared by nursing staff.

During an interview on 11/13/24 at 10:44 AM, Staff T, RN Manager, stated that the staff were to attach the medication labels printed from the medication dispensing machine when the medication was prepared.

3. Review of the hospital's policy titled, "Point of Care Testing- Use and Care of Point of Care Devices," reviewed 10/2022, showed:
- Infection control guidelines are identified for the disinfection of point of care testing meters, laboratory testing instruments and includes docking stations, handheld computers and wireless devices;
- If a device has contact with an environmental surface in the patient room or becomes contaminated with blood, body fluids or other contaminant, it must be disinfected prior to use for another patient; and
- Disinfectant wipes are available for disinfecting point of care devices.

Observation on 11/06/24 at 9:50 AM, showed Staff Q, LPN, failed to create a clean surface or use a barrier for patient care supplies when she placed intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) supplies on a bedside chair for Patient #11.

Observation on 11/06/24 at 10:28 AM, showed Staff R, LPN, failed to create a clean surface or use a barrier for supplies when she performed wound care for Patient #12.

Observation on 11/06/24 at 2:00 PM, showed Staff V, RN, failed to create a clean surface or use a barrier when she placed medications on the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) for Patient #14.

Observation on 11/13/24 at 11:24 AM, showed Staff LL, PCT, failed to create a clean work surface or use a barrier when she placed blood glucose testing supplies on the bedside table for Patient #26. She failed to clean the equipment when she exited Patient #26's room and entered Patient #27's room.

Observation on 11/13/24 at 11:31 AM, showed Staff LL, PCT, failed to create a clean work surface or use a barrier when she placed blood glucose testing supplies on Patient #27's bed.

Observation on 11/13/24 at 10:15 AM, showed Staff N, RN, failed to create a clean surface or use a barrier for medication preparation and failed to clean the WOW before she entered and exited Patient #25's room.

Observation on 11/13/24 at 1:06 PM, showed Staff N, RN, failed to create a clean work surface or use a barrier for wound care supplies and medication administration for Patient #2. She failed to clean the WOW before she entered and exited Patient #2's room.

Observation on 11/05/24 at 3:55 PM, showed Staff O, RN, touched the sterile end of the IV tubing and administered medication with the same tubing to Patient #6.

Observation with concurrent interview on 11/05/24 at 4:05 PM, showed Staff O, RN, failed to clean the WOW before she entered and exited Patient #7's room. She failed to create a clean surface or use a barrier when she placed medications on the WOW for Patient #
7. Staff O stated that she should have cleaned the WOW in between patient rooms.

During an interview on 11/14/24 at 9:51 AM, Staff K, CEO, stated that she expected staff to clean equipment after each patient use.

During an interview on 11/18/24 at 11:00 AM, Staff J, CNO, stated that staff were to clean any surface prior to using the surface, she expected staff to create a clean barrier. She did not believe there was a policy for cleaning the WOWs.

During an interview on 11/13/24 at 11:21 AM and 11/14/24 at 2:15 PM, Staff L, Infection Preventionist, stated that staff cleaned the WOWs before and after their shifts, after medication preparation and anytime it was contaminated. She expected staff to throw away contaminated IV tubing. Staff L agreed that the WOWs needed to be cleaned before and after every patient use.

During an interview on 11/18/24 at 12:07 PM, Staff I, Risk Management and Quality Director, stated that staff should use a barrier or clean the surface before using it.

4. Review of the hospital's policy titled, "Food Storage," revised 04/15/23, showed:
- The contents of the storeroom are inspected at least weekly for any unsound foods, swollen/dented cans and items for return to the vendor;
- Dented cans are separated from regular storage until picked up;
- Bulk, dry foods are stored in covered containers and labeled with the common name of the food once the original container has been opened; and
- To cover food with lids, plastic wrap or other suitable covering which is airtight to protect from dripping or contamination.

Observation with concurrent interview on 11/13/24 at 9:55 AM, in the kitchen with Staff GG, Kitchen Director, showed one dented can of pineapple chunks. Staff GG stated that the can should have been pulled out of use by the kitchen staff and moved to the dented can area in the storage room.

Review of the hospital's policy titled, "Food Labeling and Dating," revised 04/15/23, showed:
- All prepared food and food stored out of the original container, with the exception of single portion items which are being held until the next meal, are to be covered, labeled and dated;
- Food is stored in approved containers and covered;
- Manufacturers expiration dates are followed;
- Stored foods are labeled to indicate the type of product and the date prepared or date the product is to be discarded;
- Prepared pudding and custard are good for seven days;
- Gelatin and canned fruit are to be discarded after seven days;
- Items such as salad dressings are dated with the date they were opened and discarded according to the manufacturer's shelf life or a month from the open date, whichever is first;
- Salad dressings expire 14 days after opening and six months after the manufacturing date;
- Liquid eggs are dated with the date the carton is opened and the hospital follows the best used by date;
- Shredded cheeses are labeled with the date opened and discarded after one month or by the expiration date, whichever comes first; and
- Spices are labeled with the date opened and discarded one year after opening.

Observation on 11/13/24 at 9:55 AM, in the Kitchen, showed:
- Two containers of salad dressing with an expiration date of 09/03/24;
- One jar of mustard with an expiration date of 11/03/24;
- One portion of sliced onions with an expiration date of 11/11/24;
- Two containers of ginger with expiration dates of 02/08/24;
- One container of nutmeg with an expiration date of 09/10/24;
- One container of poultry seasoning with an expiration date of 11/25/23;
- Four packages of tortillas expired on 10/30/24 in a container with unexpired packages;
- One opened container of salad, single use packages of creamer, sugar, salt, pepper, salad dressings, mustard, ketchup, mayonnaise, peanut butter and jelly, without an expiration date;
- One can of sliced apples, one can of vanilla pudding, one bag of onions and 10 containers of pickles without received or expiration dates;
- One salad without a preparation or expiration date;
- Twelve custards and 12 gelatins not covered with plastic wrap and without preparation or expiration dates;
- One unsealed bag of croissants, one unwrapped bag of rosemary, one carton of liquid eggs, one carton of apple juice, two cups of unlabeled milk, one container of paprika, one container of dill weed, one package of shredded cheese and two gallons of salad dressing without opened or expiration dates;
- Opened frozen packages of onion rings, pineapple chunks, breaded ravioli and sausage without open or expiration dates; and
- Five portions of peaches without lids. The lids were at the bottom of the refrigerator.

During an interview on 11/13/24 at 9:55 AM, Staff GG, Kitchen Director, stated that he believed frozen food items were good for six months once opened. He was unable to determine when the items expired, without a written opened date. He stated that when the dry food bins stock got low the kitchen staff were to refill the bins from the original box and there was a chance product could mix from boxes with different best used by dates. He stated that this process could be improved to better label the bins with the best used by dates. He stated that he was unsure of the shelf life for salad. He expected staff to label all food items with a sticker that included the open and expiration dates.

Observation with concurrent interview on 11/13/24 at 10:35 AM, in the kitchen with Staff GG, Kitchen Director and Staff HH, Cook, showed:
- One box of mashed potatoes, one box of cream of rice, one box of cream of wheat and one box of corn starch without open or expiration dates;
- Staff HH stated that the boxes were opened that morning, and a sticker should have been placed on the boxes with the open and expiration dates, they were good for one year.
- Staff GG stated that he was unsure of the policy regarding dry boxed food items, but believed they expired in one year.

Review of the hospital's policy titled, "Food Storage," revised 04/15/23, showed refrigerator temperatures are maintained between 34 and 41°Farenheit (F) and are checked daily. Temperatures are logged and deviations from the norm are reported with action taken and recorded as appropriate.

Observation with concurrent interview on 11/13/24 at 9:55 AM, in the kitchen with Staff GG, Kitchen Director, showed the tray line refrigerator temperature logs for the month of November had no written temperatures. Staff GG stated that the temperatures should have been written.

Review of the hospital's undated document titled, "Main Kitchen Cleaning List," showed:
- The fryer was to be cleaned weekly and as needed by the cook;
- The hood was to be cleaned quarterly and as needed by an outside facility approved vendor; and
- The floors were to be cleaned daily by environmental services.

Although the requested the hospital failed to provide the kitchen cleaning logs and kitchen cleaning policy.

Observation with concurrent interview on 11/13/24 at 9:55 AM, in the kitchen with Staff GG, Kitchen Director, showed:
- Food and oil residue on the floors surrounding the oven and grill;
- Drips of a brown colored oily substance on the fryer/oven hood; and
- Staff GG stated that a cleaning logbook was not maintained for the steam tray table, fryer or grill but he believed cleaning was completed weekly on Fridays or on the weekend per the master cleaning schedule.

During an interview on 11/18/24 at 11:00 AM, Staff J, CNO, stated that she expected the kitchen staff to follow the kitchen cleaning and food storage/handling policies. The kitchen staff were to maintain daily temperature logs for the refrigerator and freezer located in the kitchen. The kitchen staff were to check the dates on the dry food items weekly. She expected the kitchen staff to maintain a cleaning log that followed the master cleaning schedule. She expected dented cans to be removed out of circulation and discarded.

During an interview on 11/14/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he expected the kitchen freezer and refrigerator temperature logs to be completed daily. He expected the kitchen staff to follow the master cleaning schedule as outlined and to document cleaning completion.

During an interview on 11/14/24 at 2:15 PM, Staff L, Infection Preventionist, stated that she expected all food, when opened and/or no longer in their original container, to be labeled with the opened and expiration dates. All food needed an expiration or a best used by date. She expected all food items to be marked with a received date. Dry food items were to be placed in the refill bins and dated with the best used by date. She expected all expired food was thrown away. She had not seen the kitchen cleaning logs. She was aware the kitchen grill and hood were cleaned quarterly and was surprised at the dripping oil from the hood.

5. Review of the hospital's policy titled, "Code Blue and Crash Cart Maintenance Nursing," reviewed 03/01/22, showed on the first day of the month the crash cart is opened, the Charge RN or designee will notify the appropriate departments of any crash cart drawer that will expire that month.

Observation on 11/12/24 at 2:19 PM, showed the Emergency Department (ED) crash carts had six expired IV tubings.

Observation on 11/12/24 at 2:35 PM, showed the Cardiac Catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) Laboratory crash cart had five expired IV tubing sets of five IV tubing sets observed.

During an interview on 11/14/24 at 2:17 PM, Staff L, Infection Preventionist, stated that the Charge Nurses on the night shift were tasked to check the crash carts for out dates and she did not expect to find expired supplies. Leadership made rounds and checked for expired supplies.

During an interview on 11/12/24 at 3:04 PM, Staff II, Cardiac Catheterization Laboratory Manager, stated that staff were expected to check supplies for expiration dates monthly.

6. Review of the undated nationally recognized Center for Disease Control (CDC) and Prevention standard, titled, "Best Practices for Environmental Cleaning in Healthcare Facilities Version Two," showed wall surfaces should be washable.

Review of the nationally recognized CDC standard titled, "Guidelines for Environmental Infection Control in Health-Care Facilities," dated 2017, showed cleaning and disinfecting environmental surfaces as appropriate are fundamental in reducing their potential contribution to the incidence of healthcare-associated infections. Contaminated surfaces can serve as reservoirs of potential pathogens.

Observation on 11/12/24 at 2:00 PM, of the ED, Cardiac Catheterization Laboratory and Inpatient Pharmacy, showed adhesive tape residue on the walls, doors, surfaces of workstations, patient rooms and patient care areas.

Observation on 11/13/24 at 9:08 AM, of the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), Critical Care Unit (CCU, a unit for people who have life-threatening injuries and illnesses), Medical Units (Four East, Four South and Four West), Psychiatric (relating to mental illness) Unit and Rehabilitation (the action of restoring someone to health or normal life through training and therapy) Unit, showed adhesive tape residue on the walls, doors, surfaces of patient rooms and patient care areas.

Observation on 11/13/24 at 2:42 PM, of the Surgical Services area, showed the operating room tables had tape residue build up on the arm rest.

Observation on 11/13/24 at 3:22 PM, of the SPD, showed:
- Tape residue on five autoclaves (a strong heated container used for chemical reactions and other processes using high pressures and temperatures, e.g. steam sterilization), three workstations, three supply drying racks and the walls;
-Three workstations had paper notes adhered to the station with tape;
- Four binders with non-laminated paper open on the desk; and
- Paper notes taped to the autoclaves.

During an interview on 11/18/24 at 11:00 AM, Staff J, CNO, stated that she did not expect to find tape adhesive residue in patient care areas, it created an uncleanable surface.

During an interview on 11/14/24 at 2:15 PM, Staff L, Infection Preventionist, stated that she expected the tape adhesive residue was removed from all patient care areas, she did not expect tape adhesive to be in the operating room.

During an interview on 11/13/24 at 3:00 PM, Staff DDD, Surgical Services Manager, stated that there was to be no residue from tape on surfaces in the Surgical Services Departments. The hospital followed the AORN and the AMII standards.

During an interview on 11/14/24 at 9:20 AM, Staff III, SPD Manager, stated that tape adhesive should have been removed and tape was not to be used in the area.

7. Review of hospital's policy titled "Cleaning Sterile Processing Room," reviewed 05/2022, directed staff to:
- Daily cleaning routine shall begin in the sterile storage area working to the decontamination side of CP;
- Pick up trash, wash and reline all the trash cans;
- Damp dust with a high duster or wall wash tool with a disinfectant wipe and clean the ceiling vents, top of cabinets and lights;
- Damp dust with disinfectant all the furniture, phones, cabinets and fire extinguishers;
- Damp dust windowsills and clean windows as necessary;
- Wash the doors and door hardware with a disinfectant wipe;
- Wash the glass doors to the cabinets with a disinfectant wipe and dry with a soft cloth;
- All stainless-steel cabinets shall be cleaned with a disinfectant wipe and dried with a soft cloth;
- Spot wash the walls with disinfectant;
- Dust mop the floor carefully so as not to stir dust;
- Place "Caution Wet Floor" signs and mop the floor with a neutral floor cleaner, attention to the areas behind the doors and under the furniture;
- Proceed in cleaning the other areas of the Central Processing (CP) office, etc.
- The last area to be cleaned shall be the decontamination side of CP. The above procedure of one thru 10 shall be followed in this area also;
- Replenish the hand soap and paper towels as needed; and
- Weekly Terminal Cleaning as needed of the vents, air conditioning grills, ceiling, walls and lights; and machine scrub the floors.

Review of the nationally recognized standards, The Association of Peri-Operative Registered Nurses (AORN) "Guideline for Environmental Cleaning," dated 2024, and The Association for the Advancement of Medical Instrumentation (AAMI) "National Guidelines Recommendations," dated 2017, showed:
- Terminally clean sterile processing areas each day the areas are used;
- Sterile processing personnel conduct critical processes, such as decontaminating, assembling, and sterilizing surgical instrumentation, in support of operating and invasive procedure rooms;
- The recommendations for terminal cleaning apply in sterile processing areas as in areas where surgical and other invasive procedures are performed;
- Sterile processing areas where decontamination occurs have some of the highest risks for environmental contamination of all perioperative areas; and
- Environmental cleaning in sterile processing areas is critical for reducing the risk of disease transmission from reservoirs of bloodborne pathogens and microorganisms in the decontamination environment.

Review of the hospital's document titled, "Daily Cleaning Log," dated 11/7/24 through 11/12/24, showed the Sterile Processing Department (SPD) trash and biohazard were removed daily, the clean area was mopped daily, the sink was cleaned daily, the decontamination room was mopped daily, and the decontamination sinks were cleaned daily. The hospital failed to follow the hospital's policy, AORN and AAMI recommendations for SPD terminal cleaning.

During an interview on 11/14/24 at 9:20 AM, with Staff III, SPD Manager, stated that she thought the floors were mopped, and high touched areas were wiped down daily, but she was not certain when the area was terminally cleaned.

Observation on 11/13/24 at 2:42 PM, of the Surgical Services area, showed:
- The PACU nurses' station had missing laminate and exposed wood covered with tape;
- The PACU had exposed misfitted tile flooring with exposed concrete;
- The PACU nurses' station had a hand washing sink with water damage on the surrounding surfaces and floor;
- The SPD had floor tiles with exposed concrete;
- The SPD had three metal workstations with rust present on the surface; and
- Three of three operating room linen/trash carts observed with rusted wheels and legs.

Review of the hospital's work orders for Surgical Services and SPD dated 11/14/24, showed:
- No work orders for the flooring repairs in SPD;
- No work orders to repair/replace the workstations in SPD;
- No work order to repair/replace the nurses' station in the Post Anesthesia Care Unit (PACU, a unit to recover after surgery); and
- Work orders dated 08/29/24 and 09/09/24, for the leaking sink at the nurses' station in the PACU had no date of repair.

During an interview on 11/14/24 at 9:51 AM, Staff K, CEO, stated that the expectation for the operating room was to be free from rust. Work orders were triaged by leadership onsite and sent to corporate for a final decision.

During an interview on 11/18/24 at 11:00 AM, Staff J, CNO, stated that she did not expect to find exposed concrete or rusted equipment in the PACU or SPD.

During an interview on 11/14/24 at 2:15 PM, Staff L, Infection Preventionist, stated that SPD surfaces needed to be easily cleanable and in good repair. She did not expect to find the nurse's station, floors or anything in disrepair. She made weekly environmental rounds in different areas; each area was seen twice per year. She did not expect repairs to take over a year to complete and was told the PACU nurses' station was to be removed and replaced. The hospital talked as a group about needed repairs/replacements and Plant Operations made plans and got cost bids. She was not sure what the process was for making determinations after bids were received. The PACU was a critical area, and she expected the work orders were addressed more quickly than the current process.

During an interview on 11/18/24 at 12:07 PM, Staff I, Risk Management and Quality Director, stated that there should not be rust in any area that was terminally cleaned.

During an interview on 11/14/24 at 9:20 AM, with Staff III, SPD Manager, stated that a request to replace the floor and the workstations was pending corporate approval. She requested the workstations be replaced due to rust and staff injuries on the sharp corners.

During an interview on 11/13/24 at 3:00 PM, Staff DDD, Surgical Services Manager, stated that there was to be no rust in the operating rooms. She did not expect the nurses' station to be in poor repair.




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50496

Based on interview, record review and policy review the hospital allowed a suicidal (SI, thoughts of causing one's own death) patient with affidavits (a written statement confirmed by oath, for use as evidence in court) to leave against medical advice without a mental health evaluation for one discharged patient (#16) of two discharged patient records reviewed. (A-0813) The hospital failed to notify a legal guardian of discharge for one discharged patient (#9) of two discharged patient records reviewed. (A-0800)

This failure had the potential to lead to unsafe discharges, inappropriate transitions of care and result in poor discharge outcomes for all patients in the hospital.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation (CoP): Discharge Planning.

Refer to A-0800 and A-0813

Based on interview, record review and policy review the hospital failed to notify a legal guardian of a patient's discharge for one discharged patient (#9) of two discharged patient medical records reviewed.

This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

1. Review of the hospital's policy titled, "Discharge Planning," revised 02/2023, showed:
- The policy purpose was to ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies.
- The hospital must include the discharge planning evaluation in the patient's record for use in establishing an appropriate discharge plan and must discuss the results of the evaluation with the patient/individual acting on his/her behalf.
- Certain high-risk populations may suffer adverse health consequences upon discharge if there is not additional discharge planning. High-risk patients may be defined as any person with combined age, health, and/or social factors which may negatively impact their post-hospital care. These may include but are not limited to mental health problems.

Review of the hospital's policy titled, "Patient Rights and Responsibilities," reviewed 03/2024, showed the patient or his/her representative has the right to participate in discharge recommendations.

Review of the hospital's document titled, "Registration Audit Trail," dated 09/21/24, showed at 3:44 PM, Patient #9's legal guardians contact information was added to the medical record.

Review of Patient #9's medical record dated 09/21/24, showed:
- At 3:03 PM, he was a 34-year-old male who presented to the ED with a complaint of right-hand pain after an altercation at a psychiatric (relating to mental illness) facility.
- At 3:06 PM, he was alert and oriented to person, place and time. His behavior was normal. Additional patient history was obtained from the patient, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and the psychiatric facility.
- At 3:41 PM, Patient #9's Conditions of Admission and Financial Responsibility consent showed he had an altered mental status (AMS, mental functioning ranging from slight confusion to coma). The consent was witnessed by Staff Y, RN, and Staff PP, Registration Clerk.
- Staff UU, Physician, discussed the plan to discharge the patient home with medication and follow-up with the patient. The patient was instructed on the importance of ensuring that this follow-up occurred as instructed. The patient was given verbal instructions at the time of discharge in addition to written discharge instructions. Patient #9 voiced an understanding and agreed with the plan.
- At 5:58 PM, Patient #9 was discharged from the ED. There was no patient or guardian signature on his discharge paperwork.
- Patient #9's emergency contact information on the face sheet included two public guardians.
- There was no documentation regarding contact with Patient #9's guardian to obtain consent for discharge notification in the medical record.

During a telephone interview on 11/07/24 at 9:30 AM, Staff Y, RN, stated that he did not recall if he called Patient #9's guardian prior to discharge. Nine times out of 10 he documented in the medical record contact with a guardian. Guardian contact information was available on the patient's face sheet.

During an interview on 11/14/24 at 9:05 AM, Staff K, CEO, stated that she expected guardians to be notified. She expected awareness of the need for legal guardian notification. The nurse should have recognized the guardian contact information on the face sheet.

During a telephone interview on 11/18/24 at 10:59 AM, Staff J, CNO, stated that she expected guardians to be notified. It was very difficult to determine which patients had guardians. If a patient transferred from a psychiatric facility, she expected the nurse to contact the facility for guardian information. The hospital had an opportunity to improve on the process.

During an interview on 11/06/24 at 1:44 PM, Staff C, ED Director, stated that she expected a patient's primary nurse to inform the guardian of the patient's plan for discharge.

Based on interview, record review and policy review, the hospital allowed a suicidal (SI, thoughts of causing one's own death) patient with affidavits (a written statement confirmed by oath, for use as evidence in court) to leave against medical advice (AMA) without a mental health evaluation for one discharged patient (#16) of two discharged patient records reviewed.

This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

1. Review of the hospital's policy titled, "AMA - Leaving Hospital AMA," reviewed 09/2023, showed:
- Patients who have the capacity to make decisions and who express their intent to leave the medical center without a written discharge order by a physician should be provided with information regarding potential risk associated with leaving AMA and should sign the appropriate release form.
- Whenever a demand is made by a patient (or the patient's legal representative) to leave the hospital before treatment is completed or contrary to the advice of the attending physician, the "Leaving Hospital Against Medical Advice" form must be completed.
- The patient's signature (or refusal to sign) must be witnessed by a hospital employee.
- If the patient refuses to sign, write, "patient refuses to sign" in the place for the patient's signature and the person who received the patient's refusal should sign the form in the designated witness space.
- Nursing staff in collaboration with the attending physician will take proper precautions to ensure that the patient leaves the hospital in a safe manner.
- Certain high-risk populations may suffer adverse health consequences upon discharge if there is not additional discharge planning. High-risk patients may be defined as any person with combined age, health, and/or social factors which may negatively impact their post-hospital care. These may include but are not limited to mental health problems.
- If the interdisciplinary team determines the patient needs follow-up behavioral healthcare, the discharge plan shall include documentation of good faith efforts to contact the patient's health plan, PCP or another appropriate provider.

Review of the hospital's document titled, "Affidavit in support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 hours," dated 07/01/24, showed:
- Police officers were dispatched to a suicidal individual.
- Dispatch advised, the individual stated he wanted police to kill him, and he would do whatever it takes to make that happen.
- After speaking to Patient #16 from a distance, the police officer was able to convince him to lay face down on the ground and he was placed in handcuffs.
- Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived, Patient #16 got into the ambulance, he jumped and ran. He was captured after a quick foot race and taken to the hospital.

Review of the hospital's document titled, "Affidavit in support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 hours," dated 07/01/24, showed:
- Patient #16 was addicted to drugs and alcohol.
- He tried to kill himself the last six years.
- Police came to the house today because he told a doctor he was going to kill himself.
- He was bipolar (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), off his medication and wanted to be killed by the police that day.
Although requested the hospital did not provide a policy for psychiatric holds.

Review of Patient #16's medical record dated 07/01/24 through 07/07/24, showed:
- At 5:18 PM, he was a 44-year-old male who presented to the Emergency Department (ED) with suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death). He reported that he drank a half bottle of tequila and a container of bleach with 6,000 milligrams (mg) of gabapentin (medication used to treat nerve pain or seizures) and 60 mg of Adderall (medication to treat attention deficit/hyperactive disorder [ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors]).
- His past medical history included PTSD, drug and alcohol use, antisocial personality disorder (mental health condition in which a person consistently shows no regard for right and wrong) versus narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance), bipolar disorder and ADHD.
- His mother reported the patient had a history of self-harm but frequently lied about ingestions in the past. He went to his "life-coach's" office where the police were notified of his suicide plan. He was taken into custody and taken to the ED.
- At 7:56 PM, an in-patient Psychiatry (the study and treatment of mental illness) consult order was placed.
- At 9:35 PM, 07/02/24 at11:29 PM, 07/03/24 at 12:01 PM, 07/04/24 at 2:48 PM, 07/05/24 at 4:46 PM and 07/06/24 at 12:43 PM, progress notes showed the plan was for a psychiatry evaluation after extubation (removal of breathing tube). "The patient cannot leave against medical advice until evaluated by psychiatry. Two affidavits on file. The patient CANNOT leave AMA!"
- At 10:23 PM, a procedure note showed the plan was for sedation and intubation (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) for patient and staff safety due to his erratic, aggressive and violent behavior.
- Just before midnight, Patient #16 was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with a diagnosis of SI, HI, alcohol intoxication, ingestion of toxic substance, suicide attempt and decreased level of consciousness.
- At 8:05 AM, his drug screen was positive for amphetamines (a class of psychoactive drugs that stimulates and speeds up the body's system) benzodiazepines (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia) and marijuana.
- At 6:22 PM, Staff BB, Mental Health Nurse Practitioner (NP, a nurse with advanced clinical education and training), recommended inpatient mental health hospitalization after medically cleared and the patient was able to safely be restarted on his mental health medications.
- At 12:20 PM, he was extubated without complication.
- At 3:07 PM, he reported combat hallucinations (seeing or hearing things which are not there).
- At 4:09 PM, he became agitated and was withdrawing.
- At 8:25 PM, he became restless and agitated. He stated, "I am hallucinating," and made threats towards staff. If he became more violent and threated staff, the plan was to request four-point restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head).
- On 07/07/24 at 4:38 AM, he remained confused and continued to have signs of withdrawal.
- At 1:47 PM, a stat (immediately) order was placed for telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) psychiatry.
- At 3:18 PM, he stated that he would give the nurse five minutes to get the PICC and urinary catheter out of him. The RN tried to calm him. He continued to escalate his anger, agitation and verbally threaten to hurt staff if he was not discharged. Telehealth psychiatry was paged twice. The psychiatric provider did not call back. The patient wanted to leave AMA and stated, "if you do not release me, I will release myself and things are gonna be ugly, I will mash you all out, bullshit."
- After the patient spoke with his mother, she called the nurse and requested the patient be kept in the hospital and transferred to the Veterans Affairs (VA) hospital.
- He continued to verbally threaten the staff to release him and did not agree to wait for "anything else" as well as he asked to stop all sedation medications, he believed it made his condition worse.
- The charge nurse and house supervisor were notified. Staff F, RN, was told to assist the patients with his right to make his own medical care decisions while maintaining patient safety. Staff F was told to send the patient to the bus stop.
- The sedative medication was stopped, urinary catheter was removed, he was dressed and sent to the ED with the assistance of hospital security and a police officer.
- The patient had no identification or money to use public transportation. He was unable to walk without assistance.
- A police officer called the patient's mother again and requested she pick the patient up. She responded that she would be at the hospital in 30 minutes.
- At 3:56 PM, he remained with hospital security while waiting for his mother's arrival.
- There was no Leaving Hospital Against Medical Advice form completed for Patient #16.

During an interview on 11/14/24 at 11:03 AM, Staff F, RN, stated that Patient #16 woke up aggressive and demanding about the restraints. He was able to "break" one of the restraints. He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). Staff F attempted to educated Patient #16 about SI, HI and the restraints. An hour later he calmed and was less violent, the restraints were removed. He called his mother and his mother called Staff F and asked that Patient #16 not be allowed to leave because he was violent. Staff F called security and restraints were reapplied. Patient #16's strength was unusual. His aggression increased and the police were called. He calmed, verbalized that his treatment was inhumane, and he was going to "sue" the hospital. Patient #16 was able to remove one of the restraints, was angry and appeared to panic in his room. He made threats, security and the police were called. He wanted to go home. Staff F contacted the charge nurse and was told he needed a psychiatric evaluation before he could discharge. Staff F was not able to assess him due to his aggression. Staff F stated that the hospital did not have a policy if a patient was A&O X 3 with SI and/or HI and wanted to leave AMA. There was a need for more guidance for the management of an extremely aggressive patient. Staff F would have documented a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) if he was able to complete one. Staff F called telehealth psychiatry twice, there was no response and he "really needed help." He was told telehealth psychiatry cared for patients on Sundays or to call the patient's attending doctor. It was "very frequent" to not have resources available on the weekends. He emailed Staff C, ED/ICU Director, regarding the lack of resources and was told "we're working on it." Staff F felt he "had to allow Patient #16 to leave AMA." He did not attempt to administer any medications or the application of violent restraints. Staff F spoke to the unit manager, charge nurse and Staff CC, Physician. Staff CC, the discharging physician, was not present to perform an assessment of Patient #16. When Staff CC was notified Patient #16 wanted to leave AMA, she asked what his current behaviors were. Staff F did not recall if Staff CC asked about a psychiatric assessment of Patient #16. Patient #16 did not have a SI/HI assessment prior to his AMA discharge. Staff F was aware Patient #16 had affidavits and he was at risk to harm himself or others. Staff C spoke with Staff F after the event and stated Patient #16 should not have been allowed to leave AMA. He did not have the resources or support he needed to manage Patient #16. Staff F recalled four to five other patients that were in the ICU after sedation and intubation for mental health crises.

During a telephone interview on 11/07/24 at 1:20 PM, Staff CC, Physician, stated that she was "pretty sure" she talked to Patient #16, and she was "okay" with his mom taking him home. He was "pretty with it" and she felt he was competent. She was unsure if she documented a SI/HI assessment in his discharge summary. She usually tried to have a plan with the patient's family. Families were able to "vouch for patients." It was common to discharge psychiatric patients into the "custody" of their families. It was a "red flag" if the family said no. She would not request a family come to pick up a patient if the family was not comfortable, she would not discharge in those circumstances. She wanted to ensure a safe discharge with the family "on board."

During an interview on 11/13/24 at 1:30 PM, Staff VV, Chief Medical Officer (CMO), stated that a suicidal patient cannot be allowed to discharge AMA. He believed staff were fearful for their safety which led to his AMA discharge. He wondered if there was time for security to respond before Patient#16 left AMA.

During an interview on 11/13/24 at 9:05 AM, Staff K, Chief Executive Officer (CEO), stated that she agreed Patient #16 should never have been allowed to discharge AMA. She saw a need for education and resources. There was an opportunity to improve provider documentation. The police were available if needed.

During an interview on 11/18/24 at 10:59 AM, Staff J, Chief Nursing Officer (CNO), stated that a CSSRs should have been done prior to Patient #16 leaving AMA. She wanted him to be evaluated by telehealth psychiatry or a MHNP before his discharge to determine if he was safe. The police stated they would not bring him back to the hospital because he was A&O X 3. She was not aware of a hospital policy for the management of a patient like Patient #16. Staff did not know what to do.

During a telephone interview on 11/18/24 at 12:00 PM, Staff I, Risk Management and Quality Director, stated that he questioned if the hospital addressed Patient #16's chief complaint. There was an opportunity to obtain a correct assessment. He should have been assessed and cleared prior to his AMA discharge. He stated he needed staff to understand AMA is "still a discharge." The physician should have discussed risk and benefits directly with the patient and documented the patient education in the medical record. Whichever provider was covering at the time was responsible to provide AMA education either on the phone or in person.

During an interview on 11/07/24 at 12:45 PM, Staff BB, MHNP, stated that Patient #16 needed to be evaluated by psychiatry once he was extubated (removal of breathing tube). Patient #16 needed to be assessed by a provider to determine if he still had SI and/or HI before he was allowed to leave AMA. She wanted to ensure he was safe. It was important Patient #16 was calm, cool and collected before he was allowed to leave AMA. It appeared Patient #16 "took a turn for the worse."

During an interview on 11/14/24 at 12:00 PM, Staff C, ED/ICU Director, stated that she did not know why Patient #16 did not have a psychiatric evaluation after his extubation in the ICU. The contracted psychiatric service could have been called. A psychiatric evaluation should have been completed before Patient #16 was allowed to leave AMA. The situation could have been handled differently; everyone was scared of him. Medication administrations, restraint application, psychiatric consult and provider involvement should have been done before he was allowed to leave AMA.