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Based on policy review, document review and interview, the facility did not ensure all steps of the grievance process were completed or that Patient #2 or their parent was provided with a written notice of the grievance decision.

Findings include:

Review of the policy "Grievance Identification & Reporting" last revised 02/16 indicates the Clinical Patient Care Liaison and responsible Department Managers will ensure all aspects of the concerns are dealt with and that improvement actions will address the identified issue. If additional time is needed to investigate, the complainant will be notified. The initial feedback and acknowledgment letter will be completed within 7 days and patient/family notification of the resolution within 30 days.

Review of Quality Assurance documents revealed on 03/13/17 at 10:22 AM Staff (H), VP of Nursing, Staff (BB), Assistant VP of Behavioral Health Nursing and Staff (CC) met with Patient #2's parents to discuss their concerns. Staff (W), ED Physician and Staff (L), Psychiatry also met with the parents on 03/13/17 at 03:30 PM.

Review of the email sent to Staff (B), Nursing Supervisor from Patient #2's parent dated 03/22/17 at 12:03 PM revealed confirmation of the two meetings held on 03/13/17. It was noted that a follow up meeting was discussed and would be scheduled in about a week.

Review of the letter sent to Patient #2's parent from Staff (G), Patient Care Liaison dated 03/24/18 revealed confirmation of the 03/22/17 email received from the complainant, a follow up conversation between Staff (G) and the complainant which occurred on 03/22/17 and that Staff (L), Psychiatry would be reaching out to Patient # 2's parent.

Interview on 03/24/18 at 01:15 PM with Staff (G), Patient Care Liaison revealed confirmation of the email sent on 3/24/17 from Patient #2's parent to Staff (H) VP of Nursing.

No documentation was found to indicate the follow-up with psychiatry occurred or that a notice of the grievance decision was provided.

Based on policy review, medical record review and interview, the clinical staff did not report a change in health status to the family/significant other in a timely manner for 2 of 20 patients (Patient # 1 and 2) and ensure a "handoff" of clinical information between medical providers. Inadequate communication has the potential to adversely impact the care provided.

Findings include:

Review of facility policy "Transfer of Internal Patients Between Clinical Services" last revised 11/15 indicates when transferring inpatients from one clinical service to another, medical providers must ensure the safety of the patient exchange with appropriate handoff of all necessary clinical information and delineate the responsibility for the communication of change in patient clinical status to families/significant others. All transfers between different services will require a verbal provider to provider handoff.

Review of medical record for Patient #1 revealed his mother is listed as his emergency contact. On 02/01/18 at 02:43 AM he was an inpatient on a behavioral health unit and required transfer to Emergency Department (ED) for medical assessment for shortness of breath and decreased oxygen saturation while sleeping. After assessment in the ED, Patient #1 was admitted to a medical unit for continued monitoring, observation and treatment for pneumonia and possible sepsis. There is no documentation in the medical record indicating that Patient #1 ' s mother was notified of the change in his condition and need for transfer to another unit. There is also no documentation found in the medical record of a verbal handoff of clinical information between medical providers when Patient #1 was admitted to the medical service after assessment in the Emergency Department on 02/01/18 at 06:00 AM.

Interview on 04/24/18 at 10:00 AM with Staff (F) Hospitalist confirmed that there was no handoff communication between him and the oncoming hospitalist during change of shift on 02/01/18 regarding Patient #1.

Review of medical record for Patient #2 revealed the Consent for Treatment document dated 03/04/17 is signed by the patient's father. The Physician/Nursing Treatment Plan updated 03/07/17 indicates that Patient #2 wishes his parents to be involved during a crisis.

Review of the 1:1 observation sheets for Patient #2 dated 03/10/17 at 07:15 PM to 03/11/17 at 02:30 PM revealed Patient #2 was displaying increased agitation, aggression and assaultive behavior resulting in the application of 4-point restraints.

Review of the Internal Medicine Physician note dated 03/11/17 at 05:29 PM revealed Patient #2's parents were updated regarding the overnight events. There is no documentation to indicate earlier notification.

Interview on 04/25/18 at 02:30 PM with Staff (A), Chief Safety Officer verified these findings.

Based on policy review, medical record review and interview, Patient #2's psychiatric needs were not met while hospitalized on the medical/surgical floor. Specifically, no scheduled psychiatric medications were ordered when he was transferred from a behavioral health unit to a medical/surgical unit and there was a delay in psychiatric consultation and/or treatment during periods of increased agitation and aggressive behavior. This has the potential to place patients and staff at risk of injury.

Findings include:

Review of policy "Interdisciplinary Assessment and Reassessment of Patient" last revised 09/15 revealed all members of the Interdisciplinary team perform reassessments. The timing, scope and intensity of reassessments are based on diagnosis, desire for care, response to previous care and change in condition/diagnosis. This policy does not address STAT assessments. The listed components of the Admission assessment do not include review of medications. The section for the risk assessment of aggressive and/or assaultive behavior in CPEP and on a Behavioral Health unit indicates re-assessment will take place when a change in behavior or mental status warrants. However, there is no criteria listed for reassessment if this type of behavior occurs on a medical/surgical unit.

Review of the Medical History & Physical dated 03/08/17 at 11:52 AM indicates Patient #2 was admitted to an inpatient medical unit after sustaining a prolonged seizure after Electroconvulsive therapy (ECT). Depakote was discontinued on 03/06/17 prior to ECT. Scheduled psychiatric medications are listed as Lithium 600 mg twice daily. However, Lithium was not re-ordered at the time of the medical admission and not restarted until 03/11/17, following 2 nights of increased agitation and aggression by Patient #2.

Review of the 1:1 observation sheet and Nursing notes dated 03/09/17 to 03/10/17 (overnight shift) revealed the Medical Physician and Security were notified per family request because Patient #2 was very agitated and unsafe. The 1:1 sitter was present. At 01:30 AM the physician assessed Patient #2 and ordered Ativan which he declined. Patient #2 was verbally combative with the family. Later, Patient #2 was jumping out of bed, verbally threatening staff and stating he wanted to fight and that the 1:1 sitter was "starting" with him. At 04:45 AM Patient #2 was transported to wait for his ECT treatment but refused. Patient #2 did not receive a psychiatric consultation and/or treatment until 03/10/17 at 08:00 AM despite his increased agitation and aggressiveness during the overnight shift.

Review of the Psychiatric Consultation dated 03/10/17 at 09:32 AM revealed Patient #2, who was seen at 08:00 AM refused treatment (ECT) this morning. It was noted that Patient #2 does not have capacity to decide on ECT at this time. He will continue to require 1:1 observation and transfer to psychiatry after cleared by medicine. Ativan 2 mg for agitation as needed was recommended.

Review of the 1:1 observation sheet and nursing notes dated 03/10/17 to 03/11/17 (overnight shift) revealed at 11:15 PM Patient #2 is hearing voices and at 12:20 AM he was yelling in the hall, trying to go out the exit. Patient #2 continued to display increased agitation, aggression and assaultive behavior resulting in the need for security staff response and the application of 4-point restraints at 03:50 AM. At 07:12 AM Ativan 2mg IM was administered and restraints were removed at 07:15 AM.

A psychiatric consult was requested by nursing on 03/10/17 at 10:32 PM but not conducted until 03/11/17 at 11:46 AM despite Patient #2 experiencing auditory hallucinations and exhibiting aggressive and assaultive behaviors.

Review of the Psychiatric consultation on 03/11/17 at 11:46 AM revealed that Depakote was stopped for ECT. Lithium was held upon transfer to medicine. Patient #2 reported auditory hallucinations last night and continues to have perceptual disturbances. Restart Lithium 300 mg twice daily, start Haldol 5 mg twice daily and add Haldol 5 mg every four hours for agitation. Utilize existing IM Haldol and Ativan for severe agitation or refusal of oral medications. Patient #2 will require transfer back to psychiatry for continued psychiatric care when a bed becomes available.

Interview with Staff (L), Psychiatry on 03/25/18 at 08:35 AM revealed patients are taken off benzodiazepines for ECT but not necessarily all medications. It was noted that Patient #2 was on 1:1 observation on the medical surgical unit and that immediate psychiatric consults were not available on this unit.

Based on medical record review, document review and interview, the facility did not report the death of Patient #1, which occurred within 30 minutes after 4-point restraints were removed, to the Centers for Medicaid and Medicare Services (CMS) Regional Office as required.

Finding include:

Review of the medical record dated 02/01/18 at 10:15 AM revealed 4-point restraints were applied to Patient #1 by nursing staff. Patient #1 became cyanotic with no respirations and cardiopulmonary resuscitation (CPR) was started. A code blue was called at 10:26 AM and the 4- point restraints were removed. Despite following advanced cardiac life support (ACLS) protocols, including intubation and emergency medication administration, resuscitative efforts were unsuccessful and the patient was pronounced at 10:56 AM.

Interview with Staff (A), Chief Safety Officer on 04/23/18 at 08:45 AM revealed a "Death in Restraints" report was sent to CMS. She produced a copy of a report, however, there is no date listed on the report and no accompanying documentation indicating when the document was sent to CMS.

Review of an email received from CMS dated 05/07/18 indicates that the facility has not submitted the required Death Reporting documentation.