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Based on observation, interview and record review, the hospital failed to have an effective Governing Body responsible for the conduct of the hospital when:

1. Registered Nurse (RN) 1 pushed Patient (Pt) 1 onto the ground outside the hospital Emergency Department (ED) and Pt 1 suffered severe head injury. RN 1 did not accurately report the actual sequence of events leading up to Pt 1's injury and hospital staff did not report the abuse and neglect in a timely manner and did not conduct a thorough investigation to determine the root cause of the incident. (Refer to A145 findings 1, 2, 3, 4, 5)

2. Licensed Nurses in the ED did not follow hospital policies and procedures meant to keep patients safe and permitted patients assessed as danger to self to be roomed without first performing safety checks of the room. (Refer to A144 findings 1)

3. Licensed Nurses in the ED were not adequately trained to provide to the needs of patients with behavioral and mental health problems. (Refer to A 144 Finding , A 145 finding 6, A1112)

4. Licensed Nurses in the Med-Surg Unit did not conduct appropriate fall risk assessments and implement appropriate interventions to prevent falls. (Refer to A395, findings 1, 2, 3, & 4)

As a result of these failures three Immediate Jeopardy situations were called:

A144
Because of the potential for serious harm to all patients in the ED at risk for suicide and staff not providing care in a safe setting an Immediate Jeopardy (IJ) situation was called under 42 CFR 482.13 (c) 2, A144 on 9/24/20 at 3:52 p.m. with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate (remove) the IJ. The following actions were implemented and validated by the survey team: All nursing staff were educated on: care of patients (including adolescents) presenting with mental health or behavioral conditions, care plan development, de-escalation techniques, frequency and content of suicide risk assessment and environmental risk assessments (including identification of ligature risks), and 1:1 observation requirements for patients in the ED under a 5150 hold (involuntary hold for patients who are a danger to themselves and/or others, or gravely disabled). The IJ was removed and the removal was validated by the survey team onsite on 10/13/20 at 4:25 p.m. with the EDD.

A145
Because of the serious harm to Pt 1 related to abuse and neglect, and the potential for harm to all patients in the ED an Immediate Jeopardy (IJ) situation was called on 9/24/20 at 3:52 p.m. under CFR 482.13 (c) 3, A145 with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate the IJ. The following actions were implemented and validated by the survey team: The CEO, CNO, QRS, and the nursing directors attended training on the process of conducting an RCA, and an RCA was completed on the incident involving Pt 1 and contributing factors were identified. The ED nursing staff were trained on de-escalation techniques for managing mental distress situations and verbal outbursts, the signs of frustration and/or burnout in staff, and strategies to prevent altercations between staff and patients. The contracted security staff completed 5150 training and training on de-escalation techniques. The staff and physicians were informed of the facts of the incident, the police department was notified about the circumstances of Pt 1's injury and provided a copy of the security video, and Pt 1's caregiver was informed about Pt 1's injury and the medical record was amended. The IJ was removed and the removal was validated by the survey team onsite on 10/13/20 at 4:25 p.m. with the EDD.

A395
Because of the serious actual harm of head injuries related to falls and the potential harm to all patients not having effective interventions in place to prevent falls, an Immediate Jeopardy (IJ) situation was called under 42 CFR 482.23, A395 on 10/1/20 at 8:08 p.m. with the CEO, CNO, QA, MSD, and EDD. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate the IJ. The following actions were implemented and validated by the survey team: All patients on the Medical Surgical inpatient unit, census of 35 were reassessed for their fall risk level; tracking tool developed and implemented to monitor all staff during each shift for completion of Fall Risk assessments and fall risk interventions for all patients; the [brand name] Fall Risk assessment scale was updated to the true [brand name] scale from the Agency of Healthcare Research and Quality (AHRQ); all Medical Surgical unit staff were educated about the updated Fall Risk assessment scale, hourly rounding, one-to-one constant observation responsibilities; Medical Surgical nursing staff were educated about accuracy of fall risk assessments, head-to-toe assessments, fall risk interventions, physical therapy referrals, medication side effects, patients' use of assistive devices, stabilization for fall injuries and post fall assessments; one-to-one constant observers were assigned to three "High" fall risk patients. The IJ was removed and the removal was validated by the survey team onsite on 10/9/20 at 4:45 p.m. with the CNO and the MSD.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.


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Based on interview and record review, the hospital failed to protect and promote patient's rights when:

1. Registered Nurse (RN) 1 pushed Patient (Pt) 1 onto the ground outside the hospital Emergency Department (ED) and Pt 1 suffered severe head injury. RN 1 did not report the actual sequence of events to leading up to Pt 1's injury to his supervisor and/or the police, hospital staff did not report the abuse and neglect in a timely manner and did not conduct a thorough investigation to determine the root cause of the incident. (Refer to A145 findings 1, 2, 3, 4, 5)

2. Licensed Nurses in the ED did not follow hospital policies and procedures meant to keep patients safe and permitted patients assessed as danger to self to be roomed without first performing safety checks of the room. (Refer to A144 findings 1)

3. Licensed Nurses in the ED were not trained on how to meet the needs of patients with behavioral and mental health problems. (refer to A 144, A 145 finding 6)

As a result of these failures, two Immediate Jeopardy (IJ) situations were called:

A144
Because of the potential for serious harm to all patients in the ED at risk for suicide and staff not providing care in a safe setting an (IJ) situation was called under 42 CFR 482.13 (c) 2, A144 on 9/24/20 at 3:52 p.m. with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate the IJ. The following actions were implemented and validated by the survey team: All nursing staff were educated on: care of patients (including adolescents) presenting with mental health or behavioral conditions, care plan development, de-escalation techniques, frequency and content of suicide risk assessment and environmental risk assessments (including identification of ligature risks), and 1:1 observation requirements for patients in the ED under a 5150 hold (involuntary hold for patients who are a danger to themselves and/or others, or gravely disabled). The IJ was removed and the removal was validated by the survey team onsite on 10/13/20 at 4:25 p.m. with the EDD.

A145
Because of the serious harm to Pt 1 related to abuse and neglect, and the potential for harm to all patients in the ED an Immediate Jeopardy (IJ) situation was called on 9/24/20 at 3:52 p.m. under CFR 482.13 (c) 3, A145 with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate the IJ. The following actions were implemented and validated by the survey team: The CEO, CNO, QRS, and the nursing directors attended training on the process of conducting an RCA, and an RCA was completed on the incident involving Pt 1 and contributing factors were identified. The ED nursing staff were trained on de-escalation techniques for managing mental distress situations and verbal outbursts, the signs of frustration and/or burnout in staff, and strategies to prevent altercations between staff and patients. The contracted security staff completed 5150 training and training on de-escalation techniques. The staff and physicians were informed of the facts of the incident, the police department was notified about the circumstances of Pt 1's injury and provided a copy of the security video, and Pt 1's caregiver was informed about Pt 1's injury and the medical record was amended. The IJ was removed and the removal was validated by the survey team onsite on 10/13/20 at 4:25 p.m. with the EDD.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on interview and record review, the hospital failed to ensure seven of 20 patients sampled (Pt 4, Pt 9, Pt 10, Pt 11, Pt 12, Pt 13, and Pt 15) were informed about the conditions of admission (COA - consent to treat and bill the patient) when the COA forms indicated "unable to sign," the COA forms were not signed by the patient, and the COA forms had illegible staff members' signatures.

These failures resulted in Pts 4, 9, 10, 11, 12, 13, and 15 not being informed of the benefit and risks of patient care services in advance of the services being furnished or discontinued.

Findings:

During a record review of Pt 4's electronic medical record (EMR), the demographic sheet (basic information about a patient including address, emergency contact, financial resources, dates of service, and other personal information), undated, indicated Pt 4 was admitted to the hospital on 9/12/20 at 12:29 a.m. and discharged on 9/23.20 at 8:47 a.m. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) indicated a stamped inscription "patient unable to sign," and indicated in hand written form the date "9/12/20." The hand written signature in the space for "signature of witness" was illegible. There was no documentation in the EMR dated 9/12/20 to 9/23/20 to indicate the reason Pt 4 was unable to sign the COA. There was no documentation in the EMR that additional attempts were made to contact Pt 4's or their representative, and that Pt 4 and/or the representative were informed about the conditions of admission to the hospital.

During a record review of Pt 9's EMR, the demographic sheet, undated, indicated Pt 9 was admitted to the hospital on 9/27/20 at 1:59 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 8/12, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form the date, " 9/27/20" and "unable to sign verbal consent due to medical condition witnessed by myself, [staff name]." The hand written signature in the space for "signature of witness" was illegible. There was no documentation in EMR dated 9/12/20 to indicate that additional attempts were made to contact Pt 9 or their representative, and that Pt 9 and/or the representative were informed about the conditions of admission to the hospital.

During a review of Pt 10's EMR, the demographic sheet, undated, indicated Pt 10 was admitted to the hospital on 9/20/20 at 4:21 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form, "9/20/20." The hand written signature in the space for "signature of witness" was unreadable. There was no documentation in EMR dated 9/20/20 to indicate that additional attempts were made to contact Pt 10 or the representative, and that Pt 10 and/or the representative were informed about the conditions of admission to the hospital.

During a review of Pt 11's EMR, the demographic sheet, undated, indicated Pt 11 was admitted to the hospital on 9/26/20 at 7:31 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form, "9/26/20." The hand written signature in the space for "signature of witness" was unreadable. There was no documentation in EMR dated 9/26/20 to indicate that additional attempts were made to contact Pt 11 or the representative, and that Pt 11 and/or the representative were informed about the conditions of admission to the hospital.

During a review of Pt 12's EMR, the demographic sheet, undated, indicated Pt 12 was admitted to the hospital on 9/28/20 at 11:14 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form, "9/28/20." The hand written signature in the space for "signature of witness" was unreadable. There was no documentation in EMR dated 9/28/20 to indicate that additional attempts were made to contact Pt 12 or the representative, and that Pt 12 and/or the representative were informed about the conditions of admission to the hospital.

During a review of Pt 13's EMR, the demographic sheet, undated, indicated Pt 13 was admitted to the hospital on 9/26/20 at 5:54 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form, "9/26/20." The hand written signature in the space for "signature of witness" was unreadable. There was no documentation in EMR dated 9/26/20 to indicate that additional attempts were made to contact Pt 13 or the representative, and that Pt 13 and/or the representative were informed about the conditions of admission to the hospital.

During a review of Pt 15's EMR, the demographic sheet, undated, indicated Pt 15 was admitted to the hospital on 9/24/20 at 2:44 p.m. The space to indicate the discharge date and time was blank. The EMR indicated a scanned document titled, "Conditions of Admission and Authorization for Treatment," dated 6/11, signature page (P), two (2) was stamped with "patient unable to sign," and indicated in hand written form, "9/24/20." The hand written signature in the space for "signature of witness" was unreadable. There was no documentation in EMR dated 9/24/20 to indicate that additional attempts were made to contact Pt 15 or the representative, and that Pt 15 and/or the representative were informed about the conditions of admission to the hospital.

During an interview on 10/6/20 at 12:20 p.m., with the Outpatient Clinical Supervisor (OCS) (covering Registration interim), The AM OCS stated admitting staff were responsible for providing patients with the COA forms, getting the forms signed by patients and/or their representative at the time of admission to the hospital. The OCS stated when patient were unable to sign the COA forms, "patient unable to sign" must be documented on the form along with the reason (i.e. altered mental status, intubated) patient was unable to sign, and should be witnessed and have staff signature.

During an interview on 10/6/20 at 12:30 p.m., with the Chief Executive Officer (CEO), the CEO state the COA forms should be witnessed and signed with two staff signatures when patients give verbal consent and/or were unable to sign the COA. The CEO stated the process was the same when verbal or telephone consent from patients' or their representative and staff were responsible for making additional attempts to provide COA and obtain signatures of the patient and/or the representative. The CEO stated she was unaware there was an issue with the hospital's informed consent process.

During a review of the facility policy and procedure titled, "Registration Forms Requiring Patient Signature," dated 4/18, the Registration Forms Requiring Patient Signature policy indicated, " ...Policy: Admissions specialist must ensure patients are registered appropriately, ensure all paperwork and forms are explained to the patient and or responsible party, and ensure all required forms are signed by the patient or responsible party [representative]...1. All patient's or the responsible party must sign the Conditions of Admissions and Authorization for Treatment form ...3. Admissions Specialist must explain all forms requiring patients or responsible party signatures at the time of registration. 4. All patients must be given a copy of forms they signed along with the Patient Rights form."

The "Registration Forms Requiring Signature," policies did not identify a process for stamping registration documents, when to go back and review the COA with the patient or patients representative, or for addressing illegible registration staff signatures on COAs and registration documents.

Based on interview and record review, the hospital failed to ensure patients in the Emergency Department (ED) at risk for suicide were provided care in a safe setting when:

1. One to one (1:1) continuous observation of suicidal patients by nursing staff or contractual security guards in the patient's room to minimize the risk for self-harm was not provided for 2 of 4 patients (Patients 2 and 3) in the ED;

2. Suicide risk assessments (process of identifying the likelihood for a person to attempt or die by suicide) for 4 of 4 patients (Patients 2, 3, 18, and 19) were not completed each shift in order to assess for on-going presence of suicidal thoughts or statements, and changes in mood and behavior which could require interventions.

3. Environmental risk assessments to identify items a patient could use to cause self- harm within the patient's room were not completed per policy for 4 of 4 patients; and objects that could be potentially used to harm or kill oneself were not removed from the ED rooms for 2 of 4 patients (Patients 2 and 3).

4. Nursing staff lacked training in the care of patients presenting to the ED with mental health and behavioral chief complaints.

5. Ligature risks (items such as cord, rope, wire, shoelaces, sheets) which could be used to self-strangulate (hang/choke) identified by the hospital in the ED rooms in May 2020 were not removed until September 2020.

These failures resulted in Patient 2 and Patient 3 attempting suicide while in the emergency department, placed Patients 18 and 19 at increased risk for self-harm, and placed all patients in the ED with mental health conditions at risk of not having their needs met in a safe setting. The failure to remove ligature risks for four months (May 2020 to September 2020) after they were identified resulted in an increased risk of self-harm to suicidal patients in the ED.

Because of the potential for serious harm to all patients in the ED at risk for suicide and ED staff not providing care in a safe setting, an Immediate Jeopardy (IJ) situation was called under 42 CFR 482.13 (c) 2, A144 on 9/24/20 at 3:52 p.m. with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted a written Action Plan (version 5) that was approved and addressed the actions needed to abate (remove) the IJ. The following actions were implemented and validated by the survey team: All nursing staff were educated on: care of patients (including adolescents) presenting with mental health or behavioral conditions, care plan development, de-escalation techniques (methods or approaches to resolve conficts), frequency and content of suicide risk assessment and environmental risk assessments (including identification of ligature risks), and 1:1 observation requirements for patients in the ED under a 5150 hold (involuntary hold for patients who are a danger to themselves and/or others, or gravely disabled). The IJ was removed and the removal was validated onsite by the survey team on 10/13/20 at 4:25 p.m. with the EDD.

Findings: (1, 2, 3, 4)

During a concurrent interview and record review on 9/10/20 at 4 p.m. with the Quality Risk Specialist (QRS), Pt 3's medical record was reviewed. Review of the ED Physician's (MD 1) documentation, "ED Assessment" dated 8/20/20 at 8:06 p.m., indicated Pt 3 was a 17-year-old brought in by ambulance on 8/20/20 at 6:38 p.m. after being placed on a 5150 hold (Welfare and Institutions code which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for a danger to self (DTS) after attempting to cut her wrists with a piece of glass. Pt 3 had a history of depression with psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and several previous 5150 holds for suicide attempts. The clinical record indicated MD 1 ordered lab tests including a drug screen and placed Pt 3 on suicide precautions (include close supervision and observation of persons with identified suicidal ideas/thoughts/verbalization) with a guard/sitter. Pt 3's lab results were within normal limits and the drug screen was negative. The record indicated on 8/20/20 at approximately 9 pm, Pt 3 was medically cleared by MD 1 and was awaiting evaluation by a mental health worker.

Review of the document "Ligature Risk Assessment" dated 8/20/20 at 7:45 p.m., indicated RN 35 had assessed the environment for safety and all potential risks for self-harm including the bed sheets had been removed from Pt 3's room.

Review of the document "Mental Health Crises Eval" dated 8/20/20 at 10:39 p.m., indicated Pt 3 was evaluated by a mental health worker and a recommendation was made to uphold the 5150 and to transfer to another facility for acute psychiatric hospitalization.

Review of the document "Continuous Observation" dated 8/20/20 and 8/21/20 indicated Pt 3 was on a gurney in the ED hallway. Hourly RN observations were documented from 8 p.m. on 8/20/20 through 1 a.m. on 8/21/20 with Pt 3 described as calm and cooperative. The notes also indicated the hospital's security guard was providing observation.

Review of the document "Continuous Observation Form-Attachment 3" dated 8/21/20, indicated every 15-minute observations by a security guard (SG) 4 from midnight on 8/20/20 through 07:45 a.m. on 8/21/20. At 1:30 a.m. on 8/21/20, the record indicated Pt 3 was sitting quietly, at 1:45 a.m. and 2 a.m. the record indicated Pt 3 was agitated and aggressive, and at 2:15 a.m. Pt 3 was restless.

Review of the document "Emergency Department Notes [Nurses' Notes]" dated 8/21/20 at 2:18 a.m. indicated, "...Pt 3 found with bedsheet around neck pulling it tight by security guard...writer [RN 35] notified by guard...Pt 3 instructed [by RN 35] to remove bedsheet from around neck...Pt 3 refusing, stating 'I just want to die' ..."

During a telephone interview with the Education Coordinator EC on 9/11/20 at 2:30 p.m., the EC stated after having a near-miss event this past May 2020 in the ED involving ligature, all of the nursing staff in ED had been educated about ligature risk within the past few months and 5150 holds. The EC stated the staff should know when and how to check the patient's environment for ligature risks and for other things a patient could use to cause self-harm. The EC stated she had not validated whether the education provided to the staff had resulted in prevention of near-miss events involving ligature or compliance with the policy for frequency of assessment.

During a concurrent interview and record review on 9/11/20 at 3:45 p.m. with the Quality Risk Specialist (QRS), Pt 2's medical record was reviewed. Review of the ED Physician's (MD 2) documentation, "ED Assessment" dated 8/19/20 at 4:13 p.m., indicated Pt 2 was a 16-year-old brought in by ambulance on 8/19/20 at 4:01 p.m. after being placed on a 5150 hold for being a danger to self (DTS). Pt 2 had a history of anxiety and depression and had "tried killing himself with a razor." The record indicated MD 2 ordered lab tests including a drug screen and placed Pt 2 on suicide precautions and constant observation with a guard/sitter. Pt 2's lab results were within normal limits and the drug screen was negative. The record indicated on 8/19/20 at approximately 8:30 pm, Pt 2 was medically cleared and was awaiting evaluation by a mental health worker.

Review of the document "Suicide Risk Assessment" completed by RN 33 on 8/19/20 at 6:37 p.m., indicated Pt 2 was "threatening suicide/self-harm with imminent intent- wanted to cut wrists" and "expressing suicidal thought with intent of imminent harm-wanted to cut wrists."
Review of the document "Constant Observation" completed by RN 33 on 8/19/20 at 6:44 p.m., indicated Pt 2 was in the ED hallway on a gurney.

Review of the document "Ligature Risk Assessment" completed by RN 33 on 8/19/20 at 6:47 p.m., indicated RN 33 had assessed the environment for safety and all potential risks for self-harm, including shoelaces had been removed from Pt 2's room.

Review of the document "Mental Health Crises Eval" dated 8/19/20 at 10:22 p.m., indicated Pt 2 was evaluated by a mental health worker and a recommendation was made to uphold the 5150 and for acute psychiatric hospitalization placement.

Review of the document "Emergency Department Notes" dated 8/19/20 at 11:17 p.m., indicated RN 25 assumed care of Pt 2.

Review of the documents "Continuous Observation Form" dated 8/19/20 and 8/20/20, indicated on 8/19/20 from 6:15 p.m. to midnight a security guard was providing one to one observation of Pt 2. On 8/20/20 the record indicated from 00:01 until 9 a.m. there was no one to one observation of Pt 2.

Review of the document "Emergency Department Notes" dated 8/20/20 at 04:34 a.m. by RN 1, indicated, "...patient was in bathroom and took shoe laces in attempt to hang himself in bathroom on handrail...patient states he was hearing voices that told him to hang himself...patient moved in front of the nurses' station to be viewed by staff..."
Review of the document "Emergency Department Notes" dated 8/20/20 at 0730 a.m., indicated Pt 2 remained in the ED hallway and there was "no available sitter" to provide one to one observation at that time. RN 25 indicated "Hourly observation documented."
The QRS verified there was no documentation by nursing staff from 8/20/20 at 00:26 until 8/20/20 at 4:34 a.m., no assessment of Pt 2's neck, and no notification to the physician regarding Pt 2's attempt to hang himself, notification of Pt 2's parent regarding this incident, or any other documentation regarding this event.

The QRS stated she was not aware of this incident, an incident report was not submitted about this occurrence, and a review of this incident or RCA (Root Cause Analysis) had not been done to determine how this event could have happened. The QRS stated when an incident report is submitted electronically it is routed to the quality/risk department and the director of the nursing unit will get notified at the same time so they would be able to start their investigation.

During a concurrent interview and record review on 9/11/20 at 4:15 p.m. with the QRS, Pt 18's medical record was reviewed. A review of the document "Patient Summary Report" indicated Pt 18 was brought in by ambulance on 9/9/20 at 9:05 p.m. after attempting suicide by medication overdose. She was placed on a 5150 hold for being a danger to self. Pt 18 was placed on a cardiac monitor, had an intravenous (into a vein) line in place, and Poison Control was consulted. The record indicated at 9:30 p.m. a Suicide Risk Assessment was completed. Pt 18 was on a gurney in the ED hallway; a security guard was providing continuous observation. The clinical record indicated Pt 18 remained on a gurney in the hallway on a monitor and with an IV in place. At 1:17 a.m. an "Environmental Risk Assessment" was completed by RN 38, and all identified risks for self -harm were removed from the "room" (hallway) except a bra and shoelaces. RN 38 indicated all cords and IV poles were removed. The record indicated Pt 18 remained on a gurney in the hallway until around 3:30 a.m. when she was moved to an ED room. The QRS verified there was no Environmental Risk Assessment of the ED room where Patient 18 was moved to.

During a concurrent interview and record review on 9/11/20 at 4:40 p.m. with the QRS, Pt 19's medical record was reviewed. A review of the document "Patient Summary Report" indicated Pt 19 was brought in by ambulance on 8/22/20 at 10:18 a.m. on a 5150 hold for being a danger to self. The record indicated Pt 19 remained in ED on an involuntary hold from 8/22/20 until 9/2/20 when Pt 19 was transferred to another facility for acute psychiatric care. A review of the documents "Ligature Risk Assessment" for the entire hospital stay indicated the assessment was completed once each day for 8/22, 8/23, 8/25, 8/26, 8/27, 8/28, 8/31, 9/1 and 9/2; it was not completed on 8/24, 8/29, and 8/30. Review of the document "Suicide Risk Assessment" for the entire hospital stay indicated, the Suicide Risk Assessment was completed once each day on 8/22, 8/23, 8/25, 8/26, 8/27, 8/28, 8/29, 9/1, and 9/2; it was not completed on 8/24, 8/30, 8/31. The QRS stated the Ligature Risk Assessment and the Suicide Risk Assessments are supposed to be completed once each shift (12-hour shift).
During an interview with the Chief Nursing Officer and the Emergency Department Director (EDD) on 9/11/20 at 5:30 p.m., the findings from the record review of Pt 2 and Pt 3 were discussed. The EDD and the CNO stated they did not know the details of these two incidences and had not investigated them. The CNO stated these occurrences would be considered near-miss events and should not have happened. The EDD stated the nursing staff had received training on ligature risks within the past couple of months prior to these events and should have removed the ligatures risks (the sheets and the shoelaces). The EDD stated the nurses should not have documented the removal of those items when they did not remove them. The EDD stated patients here on a 5150 hold should be observed at all times and not left alone in the bathroom where they can hurt themselves. The EDD stated it is her expectation that the staff complete the ligature risk assessment every shift per policy as well as the suicide risk assessment. The CNO stated the security guard company has had some difficulty providing enough coverage for the number of patients needing one to one continuous observation. The CNO stated the security guards are supposed to be in the room with the patient; in the event the patient has to be in a hallway, the CNO stated the guard should be positioned in close enough proximity to the patient to be able to see the patient at all times and react if necessary. The EDD stated the environmental risk assessment should be done as soon as possible after a patient arrives and if a patient is moved to a different room then a risk assessment of the new room needs to be done.

During a telephone interview on 9/15/20 at 12:29 p.m. with ED RN Clinical Coordinator (RN 11), stated more training for staff needs to be done regarding care of patients with mental illness. RN 11 stated they have not been given any education or training on the standard of care for adolescent patients with mental health issues and behaviors. RN 11 stated the ED needs more staff to take care of patients with high acuity who need closer observation, and there is a shortage of security guards to stay with patients who need one to one continuous observation. RN 11 stated for patient on a 5150 the room should be checked for anything the patient can use to harm themselves before the patient gets to the room. RN 11 stated when the patient gets into the room their belongings including shoes should be secured in the patient locker. RN 11 stated patients on a 5150 are not supposed to be left alone in the bathroom.
During a concurrent interview and record review with RN 1 on 9/23/20 at 1:45 p.m., Pt 2's "Emergency Department Notes" dated 8/20/20 at 4:34 a.m. were reviewed. RN 1 verified he was the author of that note although he was not the RN assigned to care for Pt 2. RN 1 recalled that Pt 2 had been in the hallway on a gurney and stated they were short staffed that night and Pt 2 did not have a guard for 1:1 observation. RN 1 stated another RN (RN 36) in ED noticed Pt 2 had been in the bathroom a long time and asked him (RN 1) to go check on Pt 2. RN 1 stated he found Pt 2 in the bathroom with his shoelaces tied together attempting to hang himself on the handrail. RN 1 stated they were able to get Pt 2 back to the gurney and into a hospital gown and he (RN 1) took Pt 2's shoes and clothes to a locker. RN 1 stated this should have occurred when the patient first got to the ED from triage.

RN 1 stated the hospital keeps changing things regarding 5150 patients and they need a clear policy with one consistent way to do things in the ED. It is hard to keep everything straight when they are changing it. RN 1 stated they are frequently short-staffed and do not have enough security guards available especially on the night shift.

RN 1 stated he has no previous experience caring for psychiatric patients, and no education about the standard of care for patients with mental health conditions. RN 1 stated he has not had any education or training about taking care of adolescents. RN 1 stated he got about one day of orientation in the ED when he started there, even though when he was hired he was told he would get three months of training.

During a telephone interview with RN 32 on 9/29/20 at 8:25 a.m., RN 32 stated he had been assigned to care for Pt 2 on 8/19/20 at 11 p.m. RN 32 stated it was his first shift working at this hospital and that he had also been assigned another patient who was critically ill. RN 32 stated he had discussed this assignment with the charge nurse (RN 1) and that RN 1 told him to take care of the critically ill patient and that RN 1 would watch Pt 2. RN 32 stated he was not aware of what had happened with Pt 2 until he was told after it had occurred. RN 32 stated when a patient at risk for suicide is admitted their clothing and shoes should be placed in the storage locker, and the patient should not be left alone unobserved or go to use the bathroom without someone watching him.

During a concurrent interview and record review with the EDD on 9/29/20 at 11:30 a.m., the EDD stated she has looked for the staffing and assignment sheet for the night shift on 8/19/20 but was not able to locate it. The EDD stated the only way to know which patients a nurse was responsible for was to check each chart. The EDD stated she does know that RN 1 was in charge the night of 8/19/20, "It was his first and only shift in charge." The EDD stated she had reviewed Pt 2's chart and that RN 33 and 36 no longer work there. The EDD stated she reviewed Pt 3's record and that RN 35 does not work there now and the security guard (SG 4) is out on leave and not available. The EDD stated the nursing documentation for both Pt 2 and Pt 3 regarding the attempts at self-harm with ligature does not have enough information to provide an explanation as to how and why these incidences occurred. The EDD stated she does not know how Pt 3 was able to get the sheet off of her gurney and tied around her neck tightly before the security guard providing 1:1 continuous observation "found" her that way. The EDD stated she is very concerned about these incidences especially since the staff had recently had mandatory education about ligature risks and their responsibility to assess the environment for safety. The EDD provided an outline of the content dated 6/8/20 and the post-tests for the topics taught, which included Suicide Safety, Ligature Risk, De-escalation techniques, and Pt Rights/5150. The EDD stated "we have a lot of work to do as a department to improve our practice. The nursing staff need more education and training, and also to be held accountable for their actions. The department needs more resources to provide the necessary observation for patients at risk for suicide."

During an interview with the QRS on 10/16/20 at 1 p.m., the QRS stated so far no review or RCA had been done about the near-miss event on 8/21/20 at 1:45 a.m. (Pt 3's attempt at self-harm using the bedsheet). The QRS stated an RCA was done on 10/2/20 about the 8/19/20 incident with Pt 2.

5. During an interview with the Chief Executive Officer (CEO) on 9/10/20 at 1:15 p.m., the CEO stated the hospital had done lot of work to educate staff following a May 2020 near-miss event in the ED involving ligature. The CEO stated she was not aware of any near-miss events in the ED involving ligature since that occurrence. The CEO stated she did remember being told about a patient in the ED involving cords from the window blinds but she did not know the specific details. or patient name. The CEO stated she thought they did an RCA, identified the blinds and removed them. The CEO stated the hospital had previously identified the blinds as a ligature risk in May 2020, and the blinds in half of the ED rooms were removed at that time.

During an interview with the CNO on 9/10/20 at 3:30 p.m., the CNO validated the window blind cords had been identified as a ligature risk in May 2020, and that the blinds had been removed from some of the rooms in May 2020. The CNO stated the blinds were not removed from the remaining ED rooms then because "we thought we were not going to put 5150 patients in those rooms." However, the CNO stated there are no restrictions about which rooms suicidal patients can be admitted to and they are placed in other rooms or hallway beds when it is busy.

During a concurrent interview and record review with the Quality Risk Specialist on 9/10/20 at 4:30 p.m., the QRS stated an RCA was done on 9/2/20 about incident involving Pt 3 which occurred on 8/23/20, not 8/21/20. The QRS stated the incident on 8/23/20 mentioned "cords" but the review did not indicate there were cords from the blinds involved. The QRS stated the room (112) that Pt 3 was in on 8/23/20 did not have blinds in it. Review of the document "RCA and Action Plan in Response to a Near-Miss Event", dated 9/2/20, indicated..."Action Item #3: the blinds were recognized to be a possible ligature risk to patients in the ED...All window blinds have been removed from the patient rooms on the west side of the emergency department; maintenance department will remove from the east side by September 11, 2020." The QRS stated she does not know why the blinds were only removed from half of the rooms in May when they were identified as a risk. The QRS stated she does not know why the blind cords were discussed in the RCA when there is no mention of blinds in the incident report or medical record. The QRS stated a review or RCA about the near-miss attempt with a bed sheet on 8/21/20 has not been done since an incident report about the event was never submitted.

During an interview with the Facilities Director (FD) on 10/7/20 at 3:35 p.m., the FD validated that the window blinds in rooms 107, 110, 112, and 114 were removed in May 2020. The FD stated the remaining blinds in rooms A2, 100,102, 103, 115, and 116 were removed on 9/11/20.

A review of the facility policy and procedure, " 5150 Holds and Behavioral Emergencies", dated 12/19, indicated, " ...The ligature risk assessment must be completed once every shift ...Patients on a 5150 hold for being a danger to self (DTS) or non-5150 suicidal patients must have a sitter/guard in the room at all times ...Patients who are a danger to others (DTO) or violent must have a security guard assigned ...the security guard must be able to visualize and have immediate physical access to the patient the entire time they are assigned to the patient ...Patients must be observed at all times ...Patients cannot be taken to a private restroom and left alone ...Patients may use the bedside commode or be escorted to the restroom with the staff in attendance in the restroom ..."

Based on observation, interview and record review, the hospital failed to protect Patients (Pt) from abuse and neglect when:

1. Registered Nurse (RN) 1 pushed Pt 1 down to the ground causing him to hit his head on the cement outside of the Emergency Department (ED) and lose consciousness;

2. RN 1 failed to provide appropriate care to Pt 1 following Pt 1's head injury;

3. RN 1 did not provide a factual statement to the hospital staff, the police, and in his documentation of the incident in Pt 1's medical record;

4. The hospital did not conduct a thorough investigation involving RN 1 and Pt 1, which included a Root Cause Analysis (RCA) in order to determine the facts surrounding the event;

5. Despite having viewed a security video showing the actual details of the event, the hospital did not seek to correct RN 1's account to the police, the ED staff, physicians, or to Pt 1's family, and did not immediately report the event as abuse to Adult Protective Services or to CDPH.

6. The staff lacked training in management of mental distress situations including verbal outbursts displayed by patients with mental disorders.

These failures resulted in Pt 1 sustaining bilateral subdural hematomas (collection of blood outside the brain caused by blunt force trauma to the head) and a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); which required transfer to a higher level of care (Hospital 2) due to the need for neurosurgical care (medical specialty in the treatment of brain injuries). RN 1's neglect in providing care to Pt 1 after Pt 1's head injury had the potential to cause further injury to Pt 1. The hospital's failure to conduct a thorough investigation and to inform the family, the staff, and the police of the actual circumstances of the incident, further victimized Pt 1. The lack of training in the management of mental distress situations placed all patients in the ED at risk for harm.

Because of the serious harm to Pt 1 related to abuse and neglect, and the potential for harm to all patients in the ED an Immediate Jeopardy (IJ) situation was called on 9/24/20 at 3:52 p.m. under CFR 482.13 (c) 3, A145 with the CEO, CNO, EDD, and QRS. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable action plan (version 5) that was approved and addressed the actions needed to abate (remove) the IJ. The following actions were implemented and validated by the survey team: The CEO, CNO, QRS, and the nursing directors attended training on the process of conducting an RCA, and an RCA was completed on the incident involving Pt 1 and contributing factors were identified. The ED nursing staff were trained on de-escalation techniques for managing mental distress situations and verbal outbursts, the signs of frustration and/or burnout in staff, and strategies to prevent altercations between staff and patients. The contracted security staff completed 5150 training and training on de-escalation techniques. The staff and physicians were informed of the facts of the incident, the police department was notified about the circumstances of Pt 1's injury and provided a copy of the security video. Pt 1's caregiver was informed about Pt 1's injury, and Pt 1's medical record was amended by the EDD to refect the actual circumstances of this event. The IJ was removed and validated onsite by the survey team on 10/13/20 at 4:25 p.m. with the EDD.

Findings:

On 9/21/20 an investigation was initiated into an Adverse Event (an incident that result in harm to the patient) reported by the facility on 9/18/20. Review of the report submitted by the Chief Nursing Officer (CNO) indicated, on 9/18/20 Pt 1 was outside of the ED doors being discharged from the ED and, "...became confrontational with the RN (RN 1), per nurse head-butted him (nurse), nurse pushed him back, Pt fell hitting head on cement...head laceration... brain to detect bleeding] showed head bleed, transferred to [Name of Hospital] for CT [Computed Tomography] a test that uses x-rays and a computer to provide detailed images of the a higher level of care..."

During a telephone interview with the CNO on 9/21/20 at 9:33 a.m., the CNO stated Pt 1 came to the hospital ED on 9/17/20 at 7:30 p.m. for a paracentesis (the insertion of a needle into the abdominal cavity for the removal of fluid). The CNO stated Pt 1 had a history of being "short-fused" and wanted to leave right away. Pt 1 was discharged on 9/18/20 at 12:30 a.m. The CNO stated Pt 1 became agitated when his ride was not there and used profanity and wanted to go back into the ED to use the telephone. The CNO stated when Pt 1 returned outside he became agitated and the observers (witnesses) stated Pt 1 walked over to RN 1 and butted RN 1's head. RN 1 put up his hands and pushed Pt 1 back and Pt 1 fell back and hit his head.

During a telephone interview with the Facilities Director (FD) on 9/22/20 at 3 p.m., the FD stated he is the FD and the Safety Officer and is the contact person for the hospital surveillance system. The FD stated he was aware of the incident involving Pt 1 and stated the incident was captured by the surveillance cameras monitoring the ED entrance and parking lot. The FD stated in addition to himself, the video was viewed by the CEO, the CNO, and the EDD.

During a concurrent interview and video review with the FD on 9/22/20 at 4 p.m., the video (no audio) of the incident on 9/18/20 involving RN 1 and Pt 1 was viewed and reflected the following:

12:38 a.m.-1239 a.m.- RN 1 with Pt 1 in ED lobby. After a few seconds, RN 1 was not visible on video. Pt 1 sat on chair by desk in ED lobby.

12:40 a.m.- Pt 1 sitting at small desk just inside the ED lobby. Pt 1 has phone receiver in hand and attempted a few times to return the receiver to the hospital phone attached to the wall. RN 2 arrived to assist Pt 1 who remained sitting. Pt 1 appeared weak, resting head in hands; there was a cane next to Pt 1.

12:43 a.m.- RN 2 was seen writing something down on a piece of paper and dialing the phone. Pt 1 remained sitting.

12:44:30 a.m.- RN 1 returned to ED lobby area next to the desk where Pt 1 was seated and RN 2 was talking on the phone. RN 1 spoke to RN 2. RN 2 left the area with another ED patient.

12:45:17 a.m.- RN 1 was seen on the phone next to the desk where Pt 1 remained seated with his head in arm resting on desk.

12:46 a.m.- RN 1 hung up phone.

12:46:30 a.m.- RN 1 exited ahead of Pt 1 out ED lobby doors to the outside; RN 1 gestured to Pt 1 to come. Pt 1 stood up slowly, supported himself with his left hand on the desk; Pt 1 walked slowly, assisted by cane. Pt 1's abdomen was very large and distended.

12:46:59 a.m.- Pt 1 walked through ED exit door to the outside. RN 1 was standing outside holding paperwork in one hand, looking toward outside entrance door waiting for Pt 1. Pt 1 walked toward wheelchair and was just ahead of RN 1.

12:47:06 a.m.- RN 1 walked quickly past Pt 1 and stood next to the wheelchair.

12:47:08 a.m.- RN 1 turned towards Pt 1, hands on wheelchair; Pt 1 walked towards wheelchair and stopped approximately 2.5-3 feet away from wheelchair and RN 1.

12:47:08-12:47:12 a.m.- RN 1 raised both arms to the side quickly halfway to shoulder level, head tilted to side; Pt 1 and RN 1 appeared to exchange words. Pt 1 was seen with cane in his left hand and his right hand appeared clenched.

12:47:12 a.m.- RN 1 and Pt 1 stood face to face next to the wheelchair in apparent confrontation; the back of Pt 1 and front of RN 1 were visible. Neither Pt 1's or RN 1's head moved noticeably when they were standing close to each other.

12:47:14 a.m. - RN 1 pushed Pt 1's upper chest with both hands. Pt 1 fell straight back landing on the cement hitting the back of his head. Pt 1's right foot appeared to make contact with part of the wheelchair as he went backwards. Pt 1 lay on his back and did not move after his head made contact with the concrete surface. Pt 1's body was limp and he appeared unconscious.

12:47:15 a.m.- 12:47:19 a.m.- RN 1 walked over to Pt 1 and grabbed Pt 1's left wrist in his (RN 1's) left hand, still holding paperwork in right hand. With Pt 1 still down on the ground, RN 1 pulled Pt 1 by the left wrist; Pt 1's head, left arm and shoulder lifted up off ground as RN 1 pulled Pt 1's body approximately 1.5 feet on the ground before RN 1 stopped.
12:47:21 a.m.- RN 1 leaning over Pt 1 touching his shoulder. RN 1 left Pt 1 who remained motionless on his back.

12:47:26 a.m.- RN 1 standing next to tent (screening tent for COVID-19 screening) located outside of the ED near the entrance.

12:47:30 a.m.- RN 1 walked into ED entrance.

12:47:32 a.m.- Pt 1 alone laying on back on ground. Pt 1's right arm moved slightly and his right knee bent. Pt 1 slowly turned to his left side as he drew his legs up and remained in that position. Blood was visible on the back of his head and concrete when he turned on the side.
12:48:16 a.m.- RN 1 and RN 2 walk out of ED to the outside. RN 2 walked on way to somewhere else, and RN 1 walked toward Pt 1.

12:48:21 a.m. -RN 1 pushed the wheelchair next to the feet of Pt 1.

12:48:29 a.m.- RN 1 stood over Pt 1. RN 1 held Pt 1's shoulder and right arm in an effort to try to pull Pt 1 up to a sitting position.

12:48:34 a.m.- Pt 1 sat with his legs out in front of him and RN 1 was behind him holding him up.

12:49:22 a.m.- The Screener (employee responsible for completing the screening process of anyone entering the hospital for signs and symptoms of COVID-19 (Corona Virus) approached RN and Pt 1 with gloves on; the Screener did not assist or touch Pt 1; Screener visible on video for approximately 10 seconds then not visible.

12:49:35 a.m.- MD 1 walked out of ED toward RN 1 and Pt 1. RN 1 was talking to MD 1 and pointed to back of Pt 1's head which was bloody.

12:50 a.m.- ED patient care tech arrived outside the ED with a gurney.

12:50:33 a.m.- MD 1 walked back into ED.

12:51:06 a.m.- Pt 1 lifted onto gurney by RN 1 and an ED tech with assist from the Screener. Pt 1 was partially on left side with knees pulled up and arms crossed. Pt 1's abdomen was exposed, very large and distended.

12:51:23 a.m.- RN 1 was talking to ED Tech. RN 1's forehead and hairline was visible with no marks, no bruise, no blood, no evidence RN 1 had been head-butted or experienced trauma to his forehead. RN 1 acted out to ED tech how he was head butted and demonstrated how he pushed Pt 1.

12:52:01 a.m.- RN 1 and ED tech transported Pt 1 into ED. The video showed a clear close up view of RN 1's forehead and hairline as they entered the ED hallway with gurney. There were no visible marks, bruises, scratches, blood or any other sign RN 1 had been head-butted or physical evidence of trauma.

A review of the Police Report dated 9/18/20, indicated the hospital called the police department on 9/18/20 at 1:14 a.m. to report a patient had assaulted a nurse. The report indicated the officer arrived at the hospital and "made contact with victim [RN 1's Name]." The report written by the responding police officer, indicated, "... [RN 1] advised he was the nurse assigned to suspect [Pt 1's name] who was a patient receiving treatment for COVID-19... [RN1] advised he was discharging the patient because the doctor had completed his treatment...[RN 1] got [Pt 1] a wheelchair and rolled him out to the front lobby which is designated for COVID-19 patients...[Pt 1] asked [RN 1] if he had called his family to come pick him up and he said he had...[RN 1] said he mentioned to the family that [Pt 1] would need to quarantine at the residence and asked them if it would be possible and the family advised that it may not be a suitable place for [Pt 1] and they would make other arrangements...[RN 1] said that [Pt 1] became upset that his family had not been called earlier to pick him up...[RN 1] told [Pt 1] he no control over who was picking him up and that he could use the lobby phone to make any arrangements if he wanted. [Pt 1] got upset at [RN 1] and kept walking closer to him until he was basically face to face with him and then headbutted him. [RN 1] stated he reacted by pushing [Pt 1] back away from him and [Pt 1] fell to the ground and hit his head...the medical staff assisted [Pt 1] and treated him for a head wound and [RN1] complained of a headache from being headbutted...[RN 1] and hospital staff wanted this incident documented and the hospital completed their own separate investigation. [RN 1] did not want prosecution...I did not contact or interview [Pt 1] based on the fact that he had a confirmed case of COVID-19 and the fact that [RN 1] was the victim and did not want prosecution..." The report was signed by the officer on 9/19/20 and a copy provided to the hospital on 9/21/20 at 10:30 a.m.

During a review of Pt 1's medical record on 9/22/20, the ED visit summary for the 9/17/20 visit, indicated Pt 1 was a 47-year-old brought in by ambulance to the ED on 9/17/20 at 7:25 pm. for complaints of increased abdominal swelling. MD 1 performed a paracentesis on Pt 1 to remove the excess fluid. The fluid was sent to the lab to check for infection. The record indicated Pt 1 did not want to wait in the ED any longer and wanted to go home. MD 1 talked to Pt 1 about why he wanted Pt 1 to wait for the lab test but Pt 1 chose to be discharged. MD 1 discharged Pt 1 and RN 1 completed the discharge paperwork. The record does not indicate the time Pt 1 was discharged to wait for his ride because the hospital was on downtime for their electronic health record. A late entry by RN 1 indicated on 9/18/20 at 12:30 a.m., "[Pt 1] became combative when discharged and headbutted RN. RN pushed patient off and he slipped, hit head occipital..."

During a review Pt 1's medical record on 9/22/20, the ED visit summary for the 9/18/20 visit, indicated Pt 1 arrived in the ED on 9/18/20 at 00:52 a.m. with a laceration to the back of the head. The record indicated Pt 1 "Assaulted another with headbutt and fell backwards during altercation and hit back of head." Pt 1 was transferred to another hospital for neurosurgical care on 9/18/20 at 4:10 a.m.

During an interview on 9/23/20 at 2:30 p.m., with RN 1, the incident involving Pt 1 on 9/18/20 was discussed. RN 1 stated he had been working in the ED since 8/2018. RN 1 stated he became an RN in 2017 and started working at the hospital in 5/2017 on the medical-surgical (med surg) unit as a new graduate. RN 1 was informed during this interview, that there was a surveillance video of the incident. RN 1 stated his shift started on 9/17/2020 at 7:00 p.m. and was assigned as a float, meaning he would help out where needed and relieve other RNs for meal breaks. RN 1 stated he was directed to relieve RN 32 and he received report on RN 32's patients. RN 1 stated after RN 32 went to break Pt 1 started getting impatient and upset and wanted to leave right away instead of waiting for the results of some lab tests. RN 1 stated the doctor discharged Pt 1 and RN 1 took Pt 1 outside the ED by wheelchair to wait for his ride. RN 1 stated it turned out that Pt 1's ride had not been called so he took Pt 1 back into the ED lobby at around 12:30 a.m. so he (Pt 1) could use the phone. RN 1 stated the triage nurse (RN 2) helped Pt 1 with the phone call. RN 1 stated he spoke to Pt 1's family member on the phone, who was concerned about the discharge because Pt 1 had COVID-19 which RN 1 was not aware of. RN 1 stated he told Pt 1 he needed to wait outside while RN 1 looked into the COVID status. RN 1 stated he waited outside for Pt 1 who was getting really angry and was cussing at him. RN 1 stated Pt 1 walked up to him outside where RN 1 was standing with the wheelchair and kept cussing at him and was angry. RN 1 alleged Pt 1 head-butted (hitting a another person's head with your head) in the forehead and he pushed Pt 1 back away from him and Pt 1 fell. RN 1 stated Pt 1 started talking to him after he fell and RN 1 stated he noticed Pt 1 was bleeding and went into the ED to let the supervisor know. RN 1 stated MD 1 came out to see Pt 1 and told RN 1 to bring Pt 1 back into the ED. RN 1 stated the tech brought a gurney and Pt 1 was brought back into the ED. RN 1 stated the police were called and he told them what had happened.

The details of the incident caught on the surveillance camera video were shared with RN 1. RN 1 stated, he thought Pt 1's head touched his head when they were standing close to each other. RN 1 stated he did not really remember trying to get Pt 1 up after the fall by pulling Pt 1 by his wrist because everything happened so fast. Pt 1 stated he thought a lot about this incident during the past five days, and does not know why he reacted the way he did to Pt 1 getting in his face. RN 1 stated he dealt with patient outbursts all of the time in the ED and should just have walked away from Pt 1 to avoid a confrontation. RN 1 stated a security guard was not present at the entrance to the ED because they had a sick call, however RN 1 stated he could have called a code gray if he needed help dealing with the patient but did not think of it at the time. RN 1 stated he should have used his phone to call for help or asked the Screener in the tent to go inside ED to get help after Pt 1 fell, instead of leaving the injured patient on the ground alone. RN 1 stated he knows "you should never leave a patient alone." RN 1 stated at the time, he did not think about the potential consequences of him moving a patient with a known head injury in the manner that he had moved Pt 1. RN 1 stated now that he had time to think he realized he "should not have moved him [Pt 1] at all" because Pt 1's neck could have been injured in the fall. RN 1 stated he does not have a good explanation for his actions after he pushed Pt 1 down, only that he "panicked" after he realized Pt 1 was injured and bleeding.

During an interview with the EDD on 9/23/20 at 4:30 p.m., the EDD stated she investigated the 9/18/20 incident and had interviewed all of the staff involved. The EDD stated she was hired full-time in July and this was her first director-level position. The EDD stated she had not received formal training on how to investigate an adverse event or how to conduct a Root Cause Analysis (RCA). The EDD stated she, the CEO, the CNO, and the FD viewed the video on 9/18/20. The EDD stated she was told to get a statement from each employee but not to question them. The EDD stated she was told not to let the staff know there was a surveillance video of the incident. The EDD stated she did not see any evidence in the surveillance video supporting RN 1's statement that he was assaulted by Pt 1 or that RN 1 pushed Pt 1 in self-defense. The EDD stated Pt 1 appeared weak and walked slowly with a cane. The EDD stated it appeared on the video that there was a confrontation between Pt 1 and RN 1 outside of the hospital. The EDD stated RN 1 could have just walked away or called security or the charge nurse if he thought he needed help. The EDD stated she did not see anything in the video that would explain why RN 1 pushed Pt 1 like he did. The EDD stated there is no explanation for RN 1 trying to move Pt 1 and then leaving Pt 1 alone laying on the concrete after the fall and to walk into the ED to tell the charge nurse. The EDD stated RN 1 could have called the charge nurse or told the Screener in the tent to call or go into ED.

During an interview with ED Clinical Coordinator (EDCC) 1 on 9/23/20 at 6:30 p.m., EDCC 1 stated she was in charge in ED on 9/18/20 at the time of the incident involving Pt 1 and RN 1. EDCC 1 stated the first time she became aware that something happened is when RN 1 came into the ED after Pt 1 had already fallen. EDCC 1 stated RN 1 told her Pt 1 had head-butted him and that he (RN1) had put his hands out and pushed Pt 1 away. EDCC 1 stated she wrote down RN 1's account of the incident but did not do any investigation of her own into what had happened. EDCC 1 stated she has not had any formal training on conducting an investigation. EDCC 1 stated she had not viewed any video of the incident or been told there was a video.

During an interview with the CNO on 9/23/20 at 7 p.m., the CNO stated she was not at the hospital when this incident happened. The CNO stated the police were called by the night shift. The CNO stated she had watched the video of the incident on 9/18/2020. The CNO stated the police were not made aware there was video of the incident.

During an interview with RN 2 on 9/24/20 at 7:30 p.m., RN 2 stated he worked as the triage nurse the night of 9/17/2020. RN 2 stated he had not viewed any video of the incident or been told there was a video regarding the incident with Pt 1. RN 2 stated Pt 1 was agitated when he first saw him in the ED lobby and he could tell Pt 1 was frustrated so he went over to help him use the phone. RN 2 stated Pt 1 was having difficulty remembering the phone number for his brother and had tried several times already, so RN 2 dialed the number and told Pt 1's brother that Pt 1 had been discharged and was waiting for a ride. Pt 1's brother told him Pt 1 was COVID positive and then RN 1 walked up and RN 2 handed RN 1 the phone and went back to work in triage. RN 2 stated he heard something was going on outside and then saw RN 1 who told him Pt 1 "head-butted me."

During a telephone interview with the Screener on 9/25/20 at 5:15 p.m., the Screener stated she was working in the tent outside of the ED at the time of the incident between Pt 1 and RN 1. The Screener stated she was hired a few months ago to do screening for anyone entering the hospital to check for COVID-19 symptoms. The Screener stated she does not have any healthcare background. The Screener stated she was not trained to do anything besides screening and did not work inside the hospital doing any patient care. The Screener stated her supervisor is the med-surg director. The Screener stated she had not viewed any video of the incident or been told there was a video. The Screener stated she saw that Pt 1 was angry and heard him saying things to RN 1 and saw Pt 1 and RN 1 standing facing each other close together. The Screener stated she thought Pt 1's head "kind of flinched a little bit" forward and saw RN 1 push Pt 1 who fell down. The Screener stated RN 1 told her Pt 1 head-butted him. The Screener stated she and RN 1 were the only staff outside at the time of the incident and that RN 1 left to go inside to tell the supervisor what had happened. The Screener stated she tried to call for assistance but was not successful because she did not know how to use the walkie-talkie. The Screener stated she did not think to go inside the ED herself to let someone know what was going on.

During a telephone interview with the ED Medical Director (EDMD) on 9/27/20 at 7:15 p.m., the EDMD stated he heard about the incident with RN 1 and Pt 1 but did not have any first-hand knowledge of the event. EDMD 1 stated he had not viewed the video of the incident.
During an interview with MD 1 on 9/28/20 at 11:15 a.m., MD 1 stated he was the physician taking care of Pt 1 prior to his discharge and then again when he was brought back in the ED after Pt 1's head injury. MD 1 stated he had not viewed the video of the incident involving Pt 1 and RN 1. MD 1 stated he had completed Pt 1's paracentesis and was waiting for the results of the lab tests on the fluid to check for infection. MD 1 stated it had been awhile and Pt 1 decided he did not want to wait any longer and wanted to leave. MD 1 stated Pt 1 was not aggressive or abusive at the time, but MD 1 could hear Pt 1's voice raised from outside of Pt 1's room. MD 1 stated he spoke with Pt 1 who was stable and explained why he wanted Pt 1 to wait for the tests and Pt 1 still wanted to leave. MD 1 stated he explained the risks to Pt 1 and gave him instructions and discharged him. MD 1 stated he did not know anything else had happened after that until he overheard RN 1 talking to EDCC 1 in the ED. MD 1 stated he heard RN 1 tell EDCC 1 he was head-butted by Pt 1, RN 1 pushed Pt 1 away in an act of self-defense, and Pt 1 fell and hit his head. MD 1 stated he walked outside and saw Pt 1 sitting on the ground with RN 1. MD 1 stated he saw Pt 1 was bleeding so he told the staff to get him back into the ED. After that Pt 1 had symptoms of head injury and the CT scan indicated Pt 1 had bilateral subdural hematomas (bleeding between the outermost layer of protective membrane surrounding the brain [the dura] and the middle membrane layer [the arachnoid]), extensive left and scattered right subarachnoid hemorrhage (bleeding between the arachnoid and the innermost membrane layer [the pia] surrounding the brain), subfalcine [midline] shift left to right (brain tissue shift away from its normal place; usually caused by a head injury), and a large posterior scalp hematoma (a collection of blood under the skin of the scalp). MD 1 then arranged for transfer to another facility for neurosurgical care. MD 1 stated RN 1 did not inform him that Pt 1 had lost consciousness when he fell and hit his head. MD 1 stated RN 1 did not tell him that he had moved Pt 1 after he hit his head. MD 1 stated when RN 1 was in ED telling EDCC 1 about what happened, MD 1 was not aware RN 1 had left Pt 1 outside; he assumed a nurse was with Pt 1.

During a telephone interview with RN 32 on 9/29/20 at 8:20 a.m., RN 32 stated he was the nurse caring for Pt 1 after his paracentesis and again after the fall and head injury. RN 32 stated he gave report to RN 1 prior to leaving for his meal break, and at that time Pt 1 was quiet and waiting to go home. RN 32 stated when he returned from break, he saw Pt 1 covered in blood on a gurney in the ED room. RN 1 was there and told him Pt 1 had head-butted him and in response he (RN 1) had pushed Pt 1 away from him and Pt 1 fell and hit his head. RN 32 stated he did not see evidence of an injury to RN 1's head, but RN 1 appeared very upset when telling him what happened. RN 32 stated he believed RN 1's account and even questioned Pt 1, asking him why he head-butted the nurse. RN 32 stated Pt 1 said he did not know what RN 32 was talking about and did not head-butt the nurse. RN 32 stated he told Pt 1 that he did head-butt the nurse, and Pt 1 responded saying he does not remember anything about that but if he did, he was sorry. RN 32 stated he would not have questioned Pt 1 like that if RN 1 had not told him Pt 1 had assaulted him. RN 32 stated Pt 1 was acting totally different after the fall and was curled up in the fetal position on his side the whole time. RN 32 stated Pt 1 developed nystagmus (a condition of rapid involuntary movements of the eyes that can be a sign of head injury or stroke) soon after the fall and also became angry and didn't want to be transferred after the CT scan showed a brain bleed. RN 32 stated MD 1 talked to Pt 1 and explained he needed to be transferred because of his condition and that he (Pt 1) was not able to make his own decisions about this because of his brain injury. Pt 1 cooperated with the transfer. RN 32 stated Pt 1's platelets (cell fragments that circulate in the bloodstream and help blood to clot) were very low but the transfer could not wait for them to administer platelets. RN 32 stated the receiving hospital was notified Pt 1 needed platelets. RN 32 stated he had not viewed the video of the incident.

During an interview with the House Supervisor (HS) 2 on 10/2/20 at 1 a.m., the HS 2 stated he was working the night of the incident with Pt 1 and RN 1. The HS 2 stated he was called by the EDCC around 30-40 minutes after it had occurred. HS 2 stated the EDCC told him Pt 1 had head-butted RN 1 in forehead. HS 2 stated he met with RN 1 in the CC's office. RN 1 told him where the incident occurred and the HS 2 stated he could see blood on the concrete. HS 2 stated RN 1 told him Pt 1 was aggressive, cussing, and obnoxious and head-butted him, so to protect himself RN 1 pushed Pt 1 back. HS 2 stated he did not see marks or bruising or other signs of a head-butting injury to RN 1's forehead.

During an interview with the Security Guard Site Supervisor (SS) on 10/15/20 at 1:20 p.m., the SS stated he was working the night of the incident involving RN 1 and Pt 1. The SS stated they were short-staffed that night so there was not a dedicated security guard assigned to the ED entrance. The SS stated he was not present when Pt 1 fell and hit his head but arrived after it had occurred. The SS stated RN 1 told him Pt 1 had head-butted him so he (RN 1) pushed him. The SS stated Pt 1 did not appear healthy and had a very large swollen abdomen. The SS stated RN 1 did not look like he had been head-butted or had any injury at all to his forehead. The SS stated he had not viewed the video of the incident.

Review of Policy titled, " Sentinel or Adverse Event Evaluation and Reporting", dated 8/2020 indicated, "...It is the policy of [Name of hospital] to investigate the source of the event, initiate any mitigating actions that may be indicated...the patient or patient's representative will be notified of the nature of the adverse event by the time the report to CDPH is made../such disclosure will be documented in the patient's medical record...[name of hospital] staff and physicians will apologize to the patient and/or family impacted by the event..."

Based on interview and record review, the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program when:

1. QAPI program failed to use data in high-risk, high-volume and problem-prone areas such as the Emergency Department and Medical-Surgical units to identify opportunities for improvement and implement changes that will lead to improvement. (Refer to A283)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on interview and record review, the hospital's Quality Assurance Performance Improvement (QAPI) program failed to use data in high-risk, high-volume and problem-prone areas such as the Emergency Department and Medical-Surgical units to identify opportunities for improvement and implement changes that will lead to improvement.

This failure resulted in a delay in implementing improvement measures that could affect health outcomes and patient safety related to fall risk safety.

Findings:


During a review of the hospital document titled,"[Name] Hospital Performance Measurement Report (PMR) 2019-2020 Department Service: Medical Surgical," dated 5/10/20, the [Name] Hospital Performance Measurement Report (PMR) 2019-2020 Department Service: Medical Surgical document indicated, " ...Performance Improvement and Quality Control Indicators ...July-Sept 2019 ...Apr-June 2020 Acton Plan if Threshold Not Met ..." The document indicated the Quality indicators and thresholds as follows:

a. Fall Risk Assessment Completed on Admission N=Number of fall risk assessment done on admission D=Number of falls per quarter with threshold goal 100% and goal met was 100% for three quarters; July-Sept 2019, Oct-Dec 2019, Jan-Mar 2020. The space to indicate the percentage goal met percentage for Apr-June 2020 was blank and there was no documentation in the Action Plan section.

b. Fall Safety Reducing fall, and assessing risk of falls among patients N=Number of falls per quarter D=Total number of patient days with threshold goal less than 3% and goal met was zero (0)% for three quarters; July-Sept 2019, Oct-Dec 2019, Jan-Mar 2020. The space to indicate the goal met percentage for Apr-June 2020 was blank and the Action Plan section indicated " ...Our goal is to reduce our number of falls for patient safety. All staff have been educated on fall risk and prevention measures. Net learning was done and completed on Fall prevention program. Bed alarms 7/8 [year not indicated] on. Assignment of sitters was done when identified as a need. New intervention for S/P [status post (after the fall)] Fall assessment completed for HER [electronic health record] [EMR brand name] ..."

During a review of the hospital document titled, "Events Review Form," opened date 9/18/20, the Events Review Form indicated " ...[Pt 4] Current approval status Manager review complete ...Event Date 9/17/20 ...Event time 21:20 [9:20 p.m.] ...Event type Fall (Patient) ...Action taken Enter action taken at the time of the event [no actions were documented] ...Name(s) of person(s) notified Concerns regarding this incident brought to [CEO] ...Per [CEO] she has taken care of it ...Severity of Harm Harm Scale No harm ...Manager Review Were lessons learned? No ...Date completed ...9/22/20 Date started ...9/21/20 ...Investigation Notes No progress notes ..." The section for the Risk Manager review had no documented entries.

During a review of the hospital document titled, "Events Review Form," opened date 9/18/20, the Events Review Form indicated " ...[Pt 5] Current approval status Being reviewed ...Event Date 9/26/20 ...Event time 22:00 [10 p.m.] Event type Fall (Patient) ...Action taken Enter action taken at the time of the event [no actions were documented] ...Parties notified at time of the event Charge Nurse House Supervisor Next of Kin Patients Physician ...Severity of Harm Harm Scale Mild harm ...Duration of Harm Temporary What type of error was this? Human error...Manager Review [no documentation entries] ...Investigation Notes ...Note ...Will track and trend ..." The section for the Risk Manager review had no documented entries.

During an interview in 9/30/20 at 9:45 a.m., with the Medical Surgical Unit Director (MSD), the MSD stated her process for investigating events was, she reviewed the electronic reports, calls and discusses the event with the patients nurse and she did not speak with the patient or other staff who were aware of the event.

During an interview on 9/30/20 at 10:10 a.m., with the MSD, the MSD stated she did not review the event report about Pt 4's fall until 9/22/20, she closed to event report that day, and she concluded by reviewing documentation in Pt 4's electronic medical record that Pt 4's bed alarm was not activated. The MSD stated she spoke to the charge nurse about Pt 4's fall but she did not document the discussion. The MSD stated she has not looked at the Fall Risk trends and was unaware of the Medical Surgical Unit's current fall rates. The MSD stated even though she has 14 days to review and resolve event reports, it was her goal to review and investigate patient fall, event reports right away; the next working day. The MSD stated " ...if it's [patient fall] unwitnessed, I need to make it a priority ...I don't understand what happened. It's a huge lesson learned ...should have investigated right away, the next day ..."

During an interview on 9/30/20 at 10:35 a.m., with the MSD, the MSD stated, " ...Our failure was, because it was an unwitnessed fall, we don't know if she [Pt 4] hit her head, needs to be a complete physical [pt needs head to toe physical assessment to determine injuries] assessment ...bed alarm was one of the things they [nurses] didn't do ..."

During an interview on 9/30/20 at 2:50 p.m. with the MSD, the MSD stated, she participated in the Root Cause Analysis (RCA) (a formal investigative and review process to determine causes of a significant event) process along with the Chief Nursing Officer (CNO), the Chief Executive Officer (CEO), and the Risk Quality Director. The MSD stated even though she knew about and attended meetings related to the RCA process, she was unaware of the how to carry out the RCA process, there was no RCA completed the event related to Pt 4's fall. The MSD stated she had received an email from the CNO asking only, if Pt 4's fall had been investigated.

During an interview on 9/30/20 at 3:05 p.m. with the CNO, the CNO stated she was aware of Pt 4's fall, she was not sure when or how she became aware, and the event reports were supposed to be "pushed over to me." The CNO stated she did not receive the electronic report related to Pt 4's fall and because their electronic reporting system was new, she did not always get the event reports. The CNO stated staff were required to report to her about "any and all events that affects patient care." The CNO stated, events that are "High Risk" such as abuse, those reports go directly to the Quality/Risk Director, the hospital has not had a Quality/Risk Director since sometime in September, and currently the CEO covers for the Quality/Risk Director. The CNO stated when Pt 4 fell, she did not investigated or follow up with the with the MSD; Pt 4's fall got pushed to the side. The CNO stated she knew the MSD would investigate the fall because the MSD was experienced and did not need direction or oversight. The CNO stated the hospital did not have a specific method to implement improvement processes and the hospital uses the new "Culture of Safety process."

During an interview on 10/5/20 at 12:55 p.m., with the CEO, the CEO stated she provided oversight to the CNO and the CNO was responsible for all the units in the hospital and she [CEO] was unaware the CNO was not providing oversight to the MSD. The CEO stated the CNO was responsible for reviewing all the electronic event reports and should be receiving event reports through email or reviewing them daily in the electronic system even if the CNO did not receive the event reports through email. The CNO stated she was aware that another patient fall had occurred over the last weekend on 10/3/20 or 10/4/20 and she did not know what to do about patient falls.

Based on observation, interviews, and record review, the hospital failed to ensure in-patients were provided with adequate and well-organized nursing services when:

1. The hospital failed to ensure nursing staff accurately and completely performed fall risk assessments, failed to implement interventions to reduce the risk for falls, used a modified fall risk assessment tool that was inconsistent with the fall risk assessment scale model indicated in the hospital policy and procedure, and failed to promptly investigate patient falls for Pt's 1, 4, 5, 9, 10, 11, 13,14, 15, and 17 (Refer to A395, Findings 1, 2, 3, & 4).

2. The hospital failed to ensure Registered Nurses (RN's) and Certified Nursing Assistants (CNAs) received the appropriate training, education, supervision, and had the specialized qualification and competence to meet the needs of patients (Refer to A397, Findings 1, 2, 3, & 4).

Because of the serious actual harm of head injuries related to falls and the potential harm to all patients not having effective interventions in place to prevent falls, an Immediate Jeopardy (IJ) situation was called under 42 CFR 482.23, A395 on 10/1/20 at 8:08 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Quality Analyst (QA), Medical Unit Surgical Director (MSD), and Emergency Department Director (EDD). The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate (remove) the IJ. The following actions were implemented and validated by the survey team: All patients on the Medical Surgical inpatient unit, census of 35 were reassessed for their fall risk level; tracking tool developed and implemented to monitor all staff during each shift for completion of Fall Risk assessments and fall risk interventions for all patients; the [brand name] Fall Risk assessment scale was updated to the true [brand name] scale from the Agency of Healthcare Research and Quality (AHRQ); all Medical Surgical unit staff were educated about the updated Fall Risk assessment scale, hourly rounding, one-to-one constant observation responsibilities; Medical Surgical nursing staff were educated about accuracy of fall risk assessments, head-to-toe assessments, fall risk interventions, physical therapy referrals, medication side effects, patients' use of assistive devices, stabilization for fall injuries and post fall assessments; one-to-one constant observers were assigned to three "High" fall risk patients. The IJ was removed and removal was verified by the survey team onsite on 10/9/20 at 4:45 p.m. with the CNO and the MSD by the survey team.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on observation, interview and record review the hospital failed to ensure nursing staff supervised and evaluated the care of each patient (Pt) when:

1. Nursing staff assigned to care for Pts 1, 4, and 5 did not accurately and completely perform fall risk assessments and/or did not conduct head-to-toe post fall nursing assessments or implement interventions to reduce the risk for falls.

2. Nursing staff used a modified fall risk assessment scale model to assess patients risk for falls that was inconsistent with the true accurate [brand name] fall risk assessment scale model indicated in the hospital policy and procedure.

3. Nursing staff did not implement Fall Risk interventions to minimize or prevent the risk for falls for Pts 1, 4, 5, 9, 10, 11, 13,14, 15, and 17.

4. Investigation of patient falls was not completed in a timely manner to determine possible causes of patient falls and to manage nursing processes for effective implementation of strategies to reduce all patients' risk for falls.

These failures resulted in injuries from falls for patients (Pts), Pt 1, Pt 4, and Pt 5 and had the potential to place all patients in the hospital at risk for falls and injury.

Because of the serious actual harm of head injuries related to falls and the potential harm to all patients not having effective interventions in place to prevent falls, an Immediate Jeopardy (IJ) situation was called under 42 CFR 482.23, A395 on 10/1/20 at 8:08 p.m. with the CEO, CNO, QA, MSD, and EDD. The hospital was provided the IJ template indicating the need to submit an acceptable written Action Plan to address the need for immediate action for the IJ situation. The hospital submitted an acceptable written Action Plan (version 5) that was approved and addressed the actions needed to abate the IJ. The following actions were implemented and validated by the survey team: All patients on the Medical Surgical inpatient unit, census of 35 were reassessed for their fall risk level; tracking tool developed and implemented to monitor all staff during each shift for completion of Fall Risk assessments and fall risk interventions for all patients; the [brand name] Fall Risk assessment scale was updated to the true [brand name] scale from the Agency of Healthcare Research and Quality (AHRQ); all Medical Surgical unit staff were educated about the updated Fall Risk assessment scale, hourly rounding, one-to-one constant observation responsibilities; Medical Surgical nursing staff were educated about accuracy of fall risk assessments, head-to-toe assessments, fall risk interventions, physical therapy referrals, medication side effects, patients' use of assistive devices, stabilization for fall injuries and post fall assessments; one-to-one constant observers were assigned to three "High" fall risk patients. The IJ was removed and removal was validated by the survey team onsite on 10/9/20 at 4:45 p.m. with the CNO and the MSD.


Findings:

1. During a concurrent interview and record review on 10/1/20 at 1:45 p.m. with the Medical-Surgical Unit Director (MSD), Pt 1's electronic medical record (EMR) dated 9/1/20 to 9/8/20 was reviewed. The EMR indicated Pt 1 was brought in by ambulance from home due to altered mental status on 9/1/20 at 01:45 a.m. and was admitted to the med-surg unit at 5 p.m. with diagnoses as follows: altered mental status with a GCS ([name]coma scale: scoring system used to describe the level of consciousness in a person following both traumatic and non-traumatic brain injury) of 13 (Severe injury: 8 or less, Moderate injury: 9-12, and Mild injury: 13-15); liver disease; and elevated ammonia level (High ammonia levels in the blood are most often result of liver disease and can cause altered mental status, tiredness, irritability, and rapid breathing). The EMR indicated the fall risk assessment dated 9/1/20 at 6:10 p.m. was completed by Registered Nurse (RN) 14 and indicated Pt 1 was confused and the fall risk assessment score was 80 (High risk ) (Normal = less than 25, Low risk = 25 - 50, and High risk = greater than 51, according to the hospital's modified [brand name] fall risk assessment model). The fall risk assessment dated 9/4/20 at 7:55 a.m. and 12:51 p.m., was completed by RN 15 and indicated Pt 1 was confused, weak and the fall risk assessment scores were 85 (High risk ). The nurse's note dated 9/4/20 at 12:19 p.m., was completed by RN 15 and indicated, " ...Patient was ambulating to the restroom when he states he lost his balance and fell. He states he hit his head and denied injury to any other parts of his body. Per [MD 4] a CT of the head was ordered. Pt was able to stand up with two-person assist and got back into his bed. Phone, call light, and bedside table, urinal within [within] reach. Pt reminded not to get up without assistance; will stay at door until sitter available." There was no documentation in the EMR to indicate what time Pt 1 was found, Pt 1's position on the floor when he was found, the location and details of the fall; what interventions were implemented before or after Pt 1's fall; or that a post fall head-to-toe assessment was completed. The MSD stated RN 15 was off and unavailable for interview for the next few days. The MSD stated nurses need to do a better job of documenting what happened, and RN 15 should have documented a head to toe assessment after the fall. The MSD stated there is no way to determine from Pt 1's EMR who found the patient and if a bed alarm was sounding at the time. The MSD stated sitters should be assigned to watch patients who were confused and were a high fall risk because patients may not follow directions about not getting up without assistance. The MSD stated bed alarms are used in part because they do not have enough staff to provide a sitter for every patient who was a High fall risk and confused. The MSD stated bed alarms are not a substitute for patients who should have a one-to-one constant observer (sitter). The MSD stated Pt 1 did not have a sitter prior to the fall, despite being confused and High risk for falls. The MSD stated she spoke with RN 15 after the fall to reinforce the expectation for accurate documentation and completion of post-fall head to toe assessments.

During a record review, Pt 4's EMR dated 9/12/20 to 9/23/20 was reviewed. The EMR patient information document indicated Pt 4 was admitted to the hospital on 9/12/20 @ 12:29 a.m. The document titled History and Physical dated 9/12/20 at 1:45 a.m., indicated Pt 4's diagnoses as follows: renal infarct (obstruction of blood flow to the kidney); anemia (a condition that makes individuals tired, caused from not enough healthy red blood cells to carry adequate oxygen to your body's tissues); elevated troponin (chemical released into the blood stream from a damaged heart muscle and may indicate a recent heart attack); and lung cancer. The fall risk assessment dated 9/13/20 at 9:50 a.m. was completed by RN 19 and indicated Pt 4's fall risk assessment score was 70 (High risk , based on the hospital's modified [brand name] fall risk assessment model). The fall risk assessment dated 9/16/20 at 11:36 p.m. was completed by CRN 5 and indicated Pt 4's fall risk assessment score was 60 (High risk ). On 9/17/20 at 7:30 a.m., Pt 4's fall risk assessment was completed by RN 21 and indicated the fall risk score was 35 (Low risk). The nurse's note dated 9/17/20 at 9:25 p.m. was completed by RN 4 and indicated, " ...2120 [9:20 p.m.] Patient was found sitting on the ground, code star was called and assisted back to bed. Patient denies hitting head, claims she was bending over to get cell phone when she felt dizzy and sat down on the ground. Patient only complaint of right shoulder pain ...Patient called husband to inform him of what happened. Reminded patient to call for assistance." There was no documentation in the EMR to indicate: Pt 4 had a change in condition that would warrant a reduction of Pt 4's fall risk assessment score from high (60) to low (35); location and details of Pt 4's fall; that the fall risk assessment for that shift was completed prior to the fall; that interventions were implemented before or after Pt 4's fall; or that a post fall head-to-toe assessment was completed. The physician notification note dated 9/22/20 at 11:07 a.m. indicated Pt 4 was confused and did not know her name or where she was. Pt 4's imaging report dated 9/22/20 at 9:44 p.m. indicated brain hemorrhage (bleeding in the brain) centered in the left temporal (side of the head beneath the temples) lobe measuring at least 5.8 x 2.7 cm (centimeters) (a unit of measure [5.7 cm = 2.2 inches and 2.7 cm = 1.1 inches approximately]), swelling, possible slight amounts of subarachnoid (surrounding area between the brain and skull) hemorrhage, and changes centered in the right occipital (lower back part of the head) skull; some swelling and thickening in the right occipital scalp area and possible underlying mass lesion (damaged tissue).

During a concurrent interview and record review on 9/30/20 at 9:45 a.m., with the Medical Surgical Unit Director (MSD), the MSD validated the findings in Pt 4's EMR date 9/12/20 to 9/23/20. The MSD stated on 9/17/20 at approximately 9: 20 p.m., Pt 4 was alone in her room, the bed alarm was not activated, and Pt 4 fell. The MSD stated Pt 4's 9/17/20, 7:30 a.m. fall risk assessment score 35 (Low risk) was not accurate and Pt 4 should have been assessed as High risk for falls. The MSD stated nursing staff did not implement interventions and activate Pt 4's bed alarm (turn on) to minimize Pt 4's risk for falls by alerting the nursing staff to provide assistance to Pt 4. The MSD stated nursing staff were required to implement fall risk interventions, including activating bed alarms for Pts assessed as Low or High risk for falls, according to hospital policy and procedure.

During a record review, Pt 5's EMR dated 9/23/20 to 9/28/20 was reviewed. The EMR patient information document indicated Pt 5 was admitted to the hospital on 9/23/20 at 9:15 p.m. The document titled History and Physical dated 9/22/20 at 10:16 p.m., indicated Pt 5 diagnoses as follows: respiratory failure; left lower lobe pneumonia; atrial fibrillation (quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications); hypertension (high blood pressure [force of the blood flowing through the veins]); back pain; left foot pain; elevated troponin; and pulmonary fibrosis (a condition in which lung tissue becomes stiff and scarred making it hard to breath). The fall risk assessment dated 9/23/20 at 7:39 p.m., was completed by RN 22 and indicated Pt 5's fall risk assessment score was 100 (High risk , based on the hospital's modified [brand name] fall risk assessment model). The fall risk assessment dated 9/26/20 at 10 a.m., was completed by RN 23 and indicated Pt 5's fall risk assessment score was 55 (High risk ). The fall risk assessment dated 9/26/20 at 7:52 p.m., was completed by RN 24 and indicated Pt 5's fall risk assessment score was 45 (Low risk). The nurse's note dated 9/26/20 at 10:30 p.m. was completed by RN 24 and indicated, " ...Pt was found sitting on the floor ...Asked pt what happened, and she stated that she was trying to ambulate [walk] alone to the bedside commode [toilet]. As she stood up she caught herself drifting to the floor. Pt denies hitting her head and denies any pain. Able to stand with assist and continued to use commode with assistance. Complete physical assessment was done. Found skin tear on left upper arm where previous bruise was located. Used steri strips to close the skin tear. Pt continued to deny any pain or discomfort ..." There was no documentation in the EMR to indicate: Pt 5 had a change in condition that would warrant a reduction of Pt 5's fall risk assessment score from high (55) to low (45); location and details about the fall; that interventions were implemented before and/or after the fall; and that a post fall risk reassessment was completed according to the hospital's fall prevention policy.

During a concurrent interview and record review on 10/1/20 at 11:50 a.m., with the MSD, the MSD validated the findings in Pt 5's EMR dated 9/23/20 to 9/28/20. The MSD stated nursing staff did not implement interventions and activate Pt 5's bed alarm (turn on) to minimize Pt 5's risk for falls by alerting the nursing staff to provide assistance to Pt 5. The MSD stated fall risk interventions were not implemented before or after Pt 5's fall, and the required post fall risk reassessment was not completed. The MSD stated it was her expectation for staff to follow the fall prevention policy; nurses are required to implement interventions including activation of bed alarms to minimize or prevent patient falls for all patients assessed as at risk. The MSD stated documenting and implementing fall risk interventions were important for nurses to know how to provide care to patients and to prevent patients from falling and harm or injury.

During a review of the facility policy and procedure titled, "Fall Prevention Program and Code Star," dated 2/19, the Fall Prevention Program and Code star policy indicated, "...Purpose: To improve patient safety by using a systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. After assessment of a patient's risk, fall prevention interventions shall be implemented. To prevent further injury to a patient ...who has fallen. Nursing fall risk assessment, diagnoses and interventions are based on use of the [brand name name] Fall Scale ...1997 ...After assessment, the nurse shall determine the fall risk scale number and initiate interventions for the appropriate risk scale ...High risk Fall Prevention Interventions (Score > [greater than] 51) ...These interventions are designed to be implemented ...designed to reduce severity of injuries due to falls ...Physical therapy screening referral for gait, balance, and transfer mobility ...Equipment ...Bed exit alarms On if available ..."

2. During a record review, the hospital's electronic [brand name name] modified fall risk assessment model and the policy and procedure titled "Fall Prevention Program and Code Star" dated 2/10 were reviewed. The hospitals electronic modified fall risk assessment was compared with the true [brand name name] document titled "[brand name] Fall Scale [fall risk assessment]" dated 2009. The differences between the hospital's modified [brand name] fall risk assessment scores and the true [brand name] document fall risk assessment scores are outlined as follows: the hospital modified model indicated "Normal" risk = less than 25 and the true model did not indicate a "Normal" fall risk category; the hospital modified model indicated "Low" risk = 25 - 50 and the true model indicated "Low" risk = 0 - 24; the hospital modified model did not have a "Moderate" risk category and the true model indicated "Moderate" risk = 25 - 44; the hospital modified model indicated "High" risk = greater than 51 and the true model indicated "High" risk = equal/greater than 45. The true [brand name] fall risk assessment model indicated six operational definitions including: history of falling; secondary diagnosis, automatic score of 15 if more than one diagnosis; ambulatory (walking/mobility) aids; automatic score of 20 for intravenous (in the vein) therapy; automatic score of 10 for weak gait and 20 for impaired gait/difficulty rising from a chair; and mental status, automatic score of 15 for forgetful of limitations. The hospital's modified model did not have operational definitions.

During a review of Pt 4's EMR fall risk assessments, the fall risk assessment dated 9/13/20 at 9:50 a.m. was completed by RN 19 and indicated Pt 4's fall risk assessment score was 70 (High risk , based on the hospital's modified [brand name] fall risk assessment model). The fall risk assessment dated 9/16/20 at 11:36 p.m. was completed by CRN 5 and indicated Pt 4's fall risk assessment score was 60 (High risk ). On 9/17/20 at 7:30 a.m., Pt 4's fall risk assessment was completed by RN 21 and indicated the fall risk score was 35 (Low risk). The nurse's note dated 9/17/20 at 9:25 p.m. was completed by RN 4 and indicated, " ...2120 [9:20 p.m.] Patient was found sitting on the ground, code star was called and assisted back to bed. Patient denies hitting head, claims she was bending over to get cell phone when she felt dizzy and sat down on the ground. Patient only complaint of right shoulder pain ...Patient called husband to inform him of what happened. Reminded patient to call for assistance." There was no documentation in the EMR to indicate Pt 4 had a change in condition that would warrant a reduction of Pt 4's fall risk assessment score from high (60) to low (35).

During a review of Pt 5's EMR fall risk assessments, the fall risk assessment dated 9/23/20 at 7:39 p.m., was completed by RN 22 and indicated Pt 5's fall risk assessment score was 100 (High risk , based on the hospital's modified [brand name] fall risk assessment model). The fall risk assessment dated 9/26/20 at 10 a.m., was completed by RN 23 and indicated Pt 5's fall risk assessment score was 55 (High risk ). The fall risk assessment dated 9/26/20 at 7:52 p.m., was completed by RN 24 and indicated Pt 5's fall risk assessment score was 45 (Low risk). The nurse's note dated 9/26/20 at 10:30 p.m. was completed by RN 24 and indicated, " ...Pt was found sitting on the floor ...Asked pt what happened, and she stated that she was trying to ambulate [walk] alone to the bedside commode [toilet]. As she stood up she caught herself drifting to the floor. Pt denies hitting her head and denies any pain. Able to stand with assist and continued to use commode with assistance. Complete physical assessment was done. Found skin tear on left upper arm where previous bruise was located. Used steri strips to close the skin tear. Pt continued to deny any pain or discomfort ..." There was no documentation in the EMR to indicate Pt 5 had a change in condition that would warrant a reduction of Pt 5's fall risk assessment score from high (55) to low (45).

During an interview on 10/1/20 at 1:20 p.m. with the MSD, the MSD validated the differences between the hospital's modified [brand name] fall risk assessment model and the true [brand name] fall risk assessment model and the findings in Pt 4's and Pt 5's EMR. The MSD stated she was not aware the modified [brand name] fall risk assessment model was different than the true [brand name] fall risk assessment model. The MSD stated the hospital's current modified [brand name] fall risk assessment model has always been used and she did not know who or when it had been changed from the true [brand name] model.

During an interview on 10/1/20 at 8:30 p.m. with the Chief Executive Officer (CEO), the differences between the hospital's modified [brand name] fall risk assessment model and the true [brand name] model were discussed. The CEO stated she was not aware that the hospital was using a modified version of the [brand name] fall risk assessment scale and she did not know who or when the scale had been modified. The CEO stated "we should be using the right one [true brand name model]" and "if we aren't using the right one, we need to change it [change the hospital model back to the unmodified version]."

During a review of the facility policy and procedure titled, "Fall Prevention Program and Code Star," dated 2/19, the Fall Prevention Program and Code star policy indicated, "...Purpose: To improve patient safety by using a systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. After assessment of a patient's risk, fall prevention interventions shall be implemented ...Policy: Nursing fall risk assessment, diagnoses and interventions are based on use of the [brand name] Fall Scale...The [brand name scale] is used widely in acute care settings. After assessment the nurse shall determine the fall risk scale number and initiate interventions for the appropriate risk scale ..."

3. During a concurrent interview and record review on 10/1/20 at 1:45 p.m. with the Medical-Surgical Unit Director (MSD), Pt 1's electronic medical record (EMR) dated 9/1/20 to 9/8/20 was reviewed. The EMR indicated Pt 1 was brought in on 9/1/20 at 1:45 a.m. by ambulance from home due to altered mental status and was admitted to the med-surg unit on 9/1/20 at 5 p.m. with diagnoses as follows: altered mental status with a GCS of 13 moderate liver disease; and elevated ammonia level in his blood. The EMR indicated the fall risk assessment dated 9/1/20 at 6:10 p.m. was completed by RN 14 and indicated Pt 1 was confused and had a fall risk assessment score was 80 (High risk ). The fall risk assessment dated 9/4/20 at 7:55 a.m. and 12:51 p.m., was completed by RN 15 and indicated Pt 1 was confused, weak and the fall risk assessment score was 85 (High risk ). The MSD stated RN 15 was off and unavailable for interview for the next few days. The MSD stated nurses need to do a better job of documenting what happened, and RN 15 should have documented a head to toe assessment after the fall. The MSD stated there is no way to determine from Pt 1's EMR who found the patient and if a bed alarm was sounding at the time. The MSD stated sitters should be assigned to watch patients who were confused and were a high fall risk because patients may not follow directions about not getting up without assistance. The MSD stated bed alarms are used in part because they do not have enough staff to provide a sitter for every patient who was a High fall risk and confused. The MSD stated bed alarms are not a substitute for patients who should have a one-to-one constant observer (sitter). The MSD stated Pt 1 did not have a sitter prior to the fall, despite being High risk for falls and confused.

During a review of Pt 4's EMR, Pt 4's fall risk assessment dated 9/16/20 at 11:36 p.m. indicated the fall risk assessment score was 60 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 4's EMR to indicate interventions were implemented on 9/16/20 at 11:36 to address Pt 4's "High" (60) fall risk assessment score.

During a review of Pt 5's EMR, Pt 5's fall risk assessment dated 9/26/20 at 10 a.m. indicated the fall risk assessment score was 55 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 5's EMR to indicate interventions were implemented on 9/26/20 at 10 a.m. to address Pt 5's "High" (55) fall risk assessment score.

During a review of Pt 9's EMR, Pt 9's fall risk assessment dated 9/28/20 at 12 a.m. indicated the fall risk assessment score was 95 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 9's EMR to indicate interventions were implemented on 9/26/20 at 12 a.m. to address Pt 9's "High" (95) fall risk assessment score.

During a review of Pt 10's EMR, Pt 10's fall risk assessment dated 9/22/20 at 7:57 a.m. indicated the fall risk assessment score was 90 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 10's EMR to indicate interventions were implemented on 9/22/20 at 7:57 a.m. to address Pt 10's "High" (90) fall risk assessment score.

During a review of Pt 11's EMR, Pt 11's fall risk assessment dated 9/27/20 at 2:11 a.m. indicated the fall risk assessment score was 70 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 11's EMR to indicate interventions were implemented on 9/27/20 at 2:11 a.m. to address Pt 11's "High" (70) fall risk assessment score.

During a review of Pt 13's EMR, Pt 13's fall risk assessment dated 9/26/20 at 9:56 p.m. indicated the fall risk assessment score was 85 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 13's EMR to indicate interventions were implemented on 9/26/20 at 9:56 p.m. to address Pt 13's "High" (85) fall risk assessment score.

During a review of Pt 14's EMR, Pt 14's fall risk assessment dated 9/22/20 at 11:51 p.m. indicated the fall risk assessment score was 70 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 14's EMR to indicate interventions were implemented on 9/22/20 at 11:51 p.m. to address Pt 14's "High" (70) fall risk assessment score.

During a review of Pt 15's EMR, Pt 15's fall risk assessment dated 9/24/20 at 11:59 p.m. indicated the fall risk assessment score was 65 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 15's EMR to indicate interventions were implemented on 9/24/20 at 11:59 p.m. to address Pt 15's "High" (65) fall risk assessment score.

During a review of Pt 17's EMR, Pt 17's fall risk assessment dated 9/25/20 at 12:45 a.m. indicated the fall risk assessment score was 70 (High risk , based on the hospital's modified [brand name] fall risk assessment model). There was no documentation in Pt 17's EMR to indicate interventions were implemented on 9/26/20 at 12:45 a.m. to address Pt 17's "High" (70) fall risk assessment score.

During a concurrent observation and interview on 10/1/20 at 8:30 p.m. with the MSD, the medical surgical unit was observed. A one-to-one Constant Observer (CO) (sitter) was sitting in a chair in the hallway outside of room 261. The CO stated she was assigned to observe three patients in three rooms, room 261, 262, and 264. The CO stated she sits in the hallway in order to have the best view of all three rooms. The CO stated all three patients need observation because they get confused and are a High risk for falling. The CO stated the practice in the past was CO were required to document continuous observation activities on a form, every 15-minutes, but when the practice was changed and COs were assigned to observations of three patients instead of one. The CO stated they (COs) stopped using the form. The MSD stated each patient should have their own constant observer (sitter), but because the hospital does not have enough staff they have to assign one sitter to three patients. The MSD stated assigning a one-to-one sitter to all the patients who needed a constant observer or were High risk for falls a sitter would require more staff more staff the hospitals current available staff.

During an interview on 10/9/20 at 12:40 p.m. with the MSD, the MSD validated the fall risk assessment findings for Pt 4, 5, 9, 10, 11, 13, 14, 15, and 17 and that the fall risk interventions were not implemented. The MSD stated completes random audits monthly of patients' records to determine nursing staff are compliant with completing the fall risk assessment each shift. The MSD stated she did not audit patient records to determine fall risk interventions were implemented and she did not review patients' medical records specifically to determine if the nurses were completing the fall risk assessments accurately based on patients' medical history. The MSD stated nurses were responsible for implementing fall risk intervention for all patients who are at risk for falls.

During a review of the facility policy and procedure titled, "Fall Prevention Program and Code Star," dated 2/19, the Fall Prevention Program and Code star policy indicated, "...Purpose: To improve patient safety by using a systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. After assessment of a patient's risk, fall prevention interventions shall be implemented ...Policy: Nursing fall risk assessment, diagnoses and interventions are based on use of the [brand name] Fall Scale...The [brand name scale] is used widely in acute care settings. After assessment the nurse shall determine the fall risk scale number and initiate interventions for the appropriate risk scale ..."

During a review of the facility policy and procedure titled, "Standards of Nursing Care Medical/Surgical," dated 1/20, the Standards of Nursing Care Medical/Surgical policy indicated, "...Purpose: To establish standards of care and clarify roles and expectations of the MCH [hospital name] nurses. To insure our nurses deliver consistent quality nursing care to MCH patients using framework from Americans Nurses Association (ANA). The new definition of nursing is to protect, promote and health promotion of our patients ...Polity: Standards of nursing care shall be adopted and followed by all licensed nursing staff ...Standards of nursing care describe the desired level of performance for registered nurses for standards of professional practice. They define the actions and behaviors expected of the RN in providing care ..."

The "Fall Prevention Program and Code Star" and the "Standards of Nursing Care Medical/Surgical," policies did not identify the process for implementing interventions that related to patients' risk for falls or for any other potential risk or medical condition.

4. During a concurrent interview and record review on 10/1/20 at 1:45 p.m. with the MSD, Pt 1's EMR dated 9/1/20 to 9/8/20 was reviewed. The EMR indicated the nurse's note dated 9/4/20 at 12:19 p.m. was completed by RN 15 and indicated "...Patient was ambulating to the restroom when he states he lost his balance and fell. He states he hit his head and denied injury to any other parts of his body. Per MD 4 a CT of the head was ordered." The MSD stated the RN was responsible for completing an occurrence report at the time of the fall or the supervisor can complete it if the nurse does not. The MSD stated she gets an alert sent to her email from the occurrence reporting system and then does her review and follow up after that. The MSD stated her review consists of reviewing the record and talking to the nurse. A review of the document titled "Event Review Form" for Pt 1's fall indicated the MSD received an email regarding this fall on 9/5/2020 at 11:08 am and had started her investigation on 9/16/20 and completed it on 9/23/20. The "Event Review Form" indicated all policies and procedures were followed and that Pt. 1 did not call for help before he got up to go to the bathroom. The MSD stated during her review she failed to identify that the intervention of having a 1 to 1 sitter for patients with a high fall risk was not implemented, or that Pt 1's confusion could make it difficult to follow directions such as calling the nurse when he needed to get up. The MSD stated when she reviewed the record she failed to identify the lack of detailed documentation regarding when the fall occurred, where Pt. 1 was found and who found him. The MSD stated she did notice the RN did not document a head to toe assessment post fall and did follow-up with the nurse.

During a concurrent interview and record review on 9/29/20 at 1:10 p.m. with the MSD, Pt 4's EMR dated 9/12/20 to 9/23/20 was reviewed. The nurse's note dated 9/17/20 at 9:25 p.m. was completed by RN 4 and indicated, " ...2120 [9:20 p.m.] Patient was found sitting on the ground, code star was called and assisted back to bed. Patient denies hitting head, claims she was bending over to get cell phone when she felt dizzy and sat down on the ground. Patient only complaint of right shoulder pain ...Patient called husband to inform him of what happened. Reminded patient to call for assistance." The physician notification note dated 9/22/20 at 11:07 a.m. indicated Pt 4 was confused and did not know her name or where she was. Pt 4's imaging report dated 9/22/20 at 9:44 p.m. indicated brain hemorrhage (bleeding in the brain) centered in the left temporal (side of the head beneath the temples) lobe measuring at least 5.8 x 2.7 cm (centimeters) (a unit of measure [5.7 cm = 2.2 inches and 2.7 cm = 1.1 inches approximately]), swelling, possible slight amounts of subarachnoid (surrounding area between the brain and skull) hemorrhage, and changes centered in the right occipital (lower back part of the head) skull; some swelling and thickening in the right occipital scalp area and possible underlying mass lesion (damaged tissue).The MSD validated the documentation in Pt 4's EMR dated 9/12/20 to 9/23/20 and Pt 4 had an unwitnessed fall on 9/17/20 at about 9:20 p.m. The MSD stated when Pts have a fall, the nurs

Based on interview and record review, the hospital failed to ensure Registered Nurses (RN's) and Certified Nursing Assistants (CNAs) received the appropriate training, education, supervision, and had the specialized qualification and competence to meet the needs of patients when:

1. The Medical Surgical Unit Director (MSD) and Emergency Department Director (EDD) did not oversee the return demonstration of nursing skills necessary to complete orientation for RN's 2, 3, 25, 26, 28, and 29 and CNAs 3 and 4.

2. The EDD did not oversee the unit re-assignment (float) process and ensure RN 18 received the proper orientation, training, and demonstrated competence to care for ED patients prior to RN 18's re-assignment to care for patients in the ED.

3. The Training Coordinator (TC) and the EDD did not oversee and ensure RN 13 and RN 29 completed the hospital's preceptor training course prior to their assignment as preceptors for newly licensed, new hire RN's (RN 12 and 27).

4. The Clinical Coordinators did not ensure that RN 2 and RN 3 had the necessary qualifications, education, specialized training, and demonstrated competency prior to being assigned to work in triage.

These failures had the potential for patients' care needs to be unmet and to compromise the health and well-being of all patients in the facility from care provided by staff who were not well trained and well qualified.

Findings:

1. During a concurrent interview and record review on 10/9/20 at 11a.m. with the Human Resources Director (HRD), personnel files for RN's 2, 3, 25, 26, 28, and 29 and CNAs 3 and 4, the findings were as follows:

Review of RN 2's personnel filed indicated RN 2's hire date was 11/4/19. The document titled "[Hospital 1] Orientation Competency Assessment Form 2018 Emergency Department Specific" had multiple incomplete skills/competency sections including: precipitous delivery (rapid labor); malignant hyperthermia (fast rise in the body's temperature and severe muscle contractions); level one infuser (system to warm up fluids or blood during surgery's) ; procedural sedation (drugs are used to depress the central nervous ); chest tubes ( hollow plastic tube is inserted between your ribs); Emergency Severity Index/triage; management of assaultive behaviors; pediatric emergencies; surge process guidelines; and wound care/measurements. The document was not dated and did not have RN 2's and/or the preceptor's signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation or return demonstration. The HRD validated the findings in RN 2's personnel file and RN 2 was assigned to the ED Unit. All orientation, skills and training documents for RN 2 were requested and no additional documents were provided from the HRD or RN 2's Unit Lead, the EDD.

Review of RN 3's personnel filed indicated RN 3's hire date was 11/4/19. The document titled "Department Orientation", page (p) 2 had RN 3's signature and the signature of the "Trainer" at next to the date 9/29/20. The trainer's signature was illegible and the identity of the trainer could not be determined. The document titled "[Hospital 1] Orientation Competency Assessment Form 2018 Emergency Department Specific" had multiple competency items (specific competency skills) next to the completion date 1/3/20. The final page, P 18 had RN 3's signature next to the date 9/29/20. The document titled "[Hospital 1] ED Environmental Orientation," had competency items dated 2/05 (without the year) and RN 3's signature next to the date 9/29/20. The document titled "Emergency Department Licensed Nurse Orientation and Skills Summary," had items next to the date 11/18 (without the year) and the final paged, p 5 had RN 3's signature next to the date 9/29/20. The spaces on the "Emergency Department Licensed Nurse Orientation and Skills Summary" document for the preceptor and clinical educator were blank. The document titled "Patient Satisfaction" was undated and unsigned. The document titled "ED Scavenger Hunt" had a printed revision date 11/6/09 and there was no date to indicate when it was completed. The HRD validated, RN 3 did not turn in his competency skills checklists and orientation documents until 9/29/20. The HRD validated the findings in RN 3's personnel file and stated RN 3 was an ED RN. The HRD stated the HR department just files the skills competency documents in the employees' personnel files and she did not look to see that the documents were completed. The HRD stated she did not know the reason RN 3's skills competency and orientation documents were incomplete and not turned in until 9/29/20. The HRD validated the findings in RN 3's personnel file and RN 3 was assigned to the ED. All orientation, skills and training documents for RN 3 were requested and no additional documents were provided from the HRD or RN 3's Unit Lead, the EDD.

Review of RN 25's personnel file indicated RN 25's hire date was 4/6/20. The document titled "Medical/Surgical Licensed Skills Checklist," undated, indicated, "This summary grid will be completed for all employees to demonstrate their job competency. The competency addresses the specific job task and to what level the employee has demonstrated the necessary knowledge, attitude and skills in their performance ..." The spaces to indicate skills completion date and initials were blank under the sections including: wound care; drains care; suction; [brand name] catheters; nasogastric tube( insertion of a plastic tube through the nose, past the throat, and down into the stomach.) tasks; chest tubes; intake and output; cultures; and forensic unit. The two remaining sections, medication administration had three of nine incomplete tasks and the intravenous (in the vein) skill section had five of six incomplete tasks. The document was not dated and did not have RN 25's or the preceptor's signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation or return demonstration. The HRD validated the findings in RN 25's personnel file and RN 25 was assigned to the Medical, Surgical Unit. All orientation, skills and training documents for RN 25 were requested and no additional documents were provided from the HRD or RN 25's Unit Lead, the MSD.

Review of RN 26's personnel file indicated RN 26's hire date was 11/27/19. The document titled "New Grad Nurse Residency 12 week Orientation Checklist,' undated, indicated, "This summary grid will be completed for all employees to demonstrate their job competency. The competency assessment addresses the specific job task and to what level the employee has demonstrated the necessary knowledge, attitude and skill in their performance. The document had RN 26's hand written name and date 12/8/19 on p 1 in the top right corner. The document was incomplete and did not have the preceptor's signature to indicate the skills and competency tasks had been completed. The HRD validated the findings in RN 26's personnel file and RN 26 was assigned to the Medical, Surgical Unit. All orientation, skills and training documents for RN 26 were requested and no additional documents were provided from the HRD or RN 26's Unit Lead, the MSD.

Review of RN 28's personnel file indicated RN 28's hire date was 2/21/20. The document titled "Medical/Surgical Licensed Skills Checklist," undated, indicated, "This summary grid will be completed for all employees to demonstrate their job competency. The competency addresses the specific job task and to what level the employee has demonstrated the necessary knowledge, attitude and skills in their performance ..." The spaces to indicate skills completion date and initials were blank under the sections including: drains care; medication administration; suction; IV skills; [brand name] catheters; nasogastric tube tasks; chest tubes; intake and output; cultures; and forensic unit. The document was not dated and did not have RN 28's and/or the preceptor's signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation or return demonstration. The HRD validated the findings in RN 28's personnel file and RN 28 was assigned to the Medical, Surgical Unit. All orientation, skills and training documents for RN 28 were requested and no additional documents were provided from the HRD or RN 28's Unit Lead, the MSD.

Review of RN 29's personnel filed indicated RN 29's hire date was 4/22/20. The document titled "[Hospital 1] Orientation Competency Assessment Form 2018 Emergency Department Specific" had multiple incomplete skills/competency sections including: evaluation of rules and conduct; malignant hyperthermia; level one infuser; Emergency Severity Index/Triage; and pediatric emergencies. The document's final page 18 was not dated and did not have RN 29's and/or the preceptor's signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation or return demonstration. The HRD validated the findings in RN 29's personnel file and RN 29 was assigned to the ED Unit. All orientation, skills and training documents for RN 29 were requested and no additional documents were provided from the HRD or RN 29's Unit Lead, the EDD.

Review of CNA 3's personnel filed indicated CNA 3's hire date was 11/4/19. The document titled "Constant Observer Skills Checklist," undated, had multiple incomplete skills sections including: provision of diversion activities to patients; identification of escalating patient behavior and need for immediate reporting; equipment safety and monitoring; infection control; forensic unit; policies and procedures; mandated reporting. The document's final page 3 was incomplete, was not dated, and did not have CNA 3's or the Unit Manager (EDD) signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation and/or return demonstration. The HRD validated the findings in CNA 3's personnel file and CNA 3 was assigned as a constant observer in the ED Unit. All orientation, skills and training documents for CNA 3 were requested and no additional documents were provided from the HRD or CNA 3's Unit Lead, the EDD.

Review of CNA 4's personnel filed indicated CNA 4's hire date was 11/4/19. The document titled "Nursing Assistant Constant Observer Skills Checklist," undated, had multiple incomplete skills sections including: patients' personal hygiene; linen changes; bathing; positioning and ambulation; dietary needs; intake and output; specimen collection; vital signs; treatments and procedures; preoperative care; admission responsibilities; patient comfort; safety; equipment; infection control; forensic unit; policies and procedures; and reporting mandates. The document's final page 4 was incomplete, was not dated, and did not have CNA 4's or the Unit Manager (EDD) signatures to indicate the skills and competency tasks had been successfully completed and validated through direct observation and/or return demonstration. The HRD validated the findings in CNA 4's personnel file and CNA 4 was assigned as a constant observer in the ED Unit. All orientation, skills and training documents for CNA 4 were requested and no additional documents were provided from the HRD or CNA 4's Unit Lead, the EDD.

During an interview on 10/9/20 at 11:20 a.m., the HRD stated generally, employees were required to have their skills checklists completed by 90 days after their date of hire date so the Unit head [MSD and EDD] can evaluate the employees progress, if they [staff] were meeting their skill expectations and to provide feedback on their performance. The HRD stated the MSD, EDD and all the department were required to complete 90 day evaluation as well as pert of the orientation and competency process.

2. During a concurrent observation and interview in the emergency department on 10/11/20 at 10:08 a.m., RN 18 was observed providing care to Pts in the ED. Charge RN (CRN) 2 stated in the spirit of transparency, we have an ICU [intensive care unit] nurse [RN 18] covering today who is not aware of all the education and changes, it is a lot of information and hard for them to know all of it when being told at the start of shift. CRN 2 stated when making the schedule we try not to assign the float nurses any 5150 [72 hour retention of patient who present a danger to self or others] patients but it could happen; it would be better if the hospital had a set (specific) float nurses but they don't. CRN 2 validated that nurses float to the ED from other units; labor and delivery (L&D), intensive care unit (ICU), Medical/Surgical (MS), and other units.

During an interview on 10/12/20 at 1:35 p.m., with the EDD, the EDD validated RN 18 was floated from the Intensive Care Unit (ICU) to the ED for about four hours during the day shift on 10/11/20 and RN 18 had not completed the orientation competencies and skills to provide care to patients in the ED. The EDD stated she was not aware of any ED orientation, skills, or competencies checklist for RN 18 and staff were not generally supposed to float to other units without first being oriented, trained and demonstrated competence in the unit where they were floated. The EDD stated staff were floated to the ED from other areas in the hospital when the ED was short staffed. The ED orientation, skills training and competencies for RN 18 were requested and not received.

During a review of the hospital policy and procedure titled, "Float Policy," dated 2/20, the Float Policy indicated, " ...Purpose: To ensure adequate, qualified staffing to meet the needs of patients in all nursing units. To promote nursing team work, efficiency and flexibility ...Policy: Non-Supervisory Nursing Staff may volunteer or be asked to assist in patient care on a unit to which they were not scheduled to work in order to provide adequate personnel to ensure patient safety and to maintain a high quality of patient care. This re-assignment of staff is referred to as floating and occurs on a shift to shift/day to day basis. Volunteer floating must be approved by the Dept. Director on a shift to shift basis ...Procedure ...3. Float nurses may be assigned to a nursing unit outside their regular dept. to float to provide services within their area of clinical competence and expertise ...6. Each float nurse will work under the supervision of a regularly scheduled staff member who will serve as the nurse's resource person. 7. The unit receiving a float nurse is responsible to assure the float nurse receives appropriate supervision and just in time orientation to the unit. The float nurse works under the supervision of a charge nurse or other assigned nurse ...9. Records of competency for each nurse, were maintained in the employee's dept. file. 10. The receiving department charge nurse or designated nurse responsible for patient assignments must: Verify competency of the float staff. Assign float nurse to patient care duties within the scope of the nurse's competency. Complete a unit orientation form (if not already on file) ..."

3. Review of the hospital document titled, "ED Daily Room Assignments," dated 10/12/20, 0700 [7 a.m.], the ED Daily Room Assignments document indicated, RN 13 was assigned as the primary nurse to ED rooms 100, 101 - 103, and BH [Behavioral Health] 2 and RN 12 (Orientee) was also assigned to ED rooms 100, 101 - 103, and BH with RN 13. The ED Daily Room Assignment document indicated RN 29 was assigned as the primary nurse to ED rooms 111, 112 - 116, and BH 6 and RN 27 (Orientee) was also assigned to ED rooms 111, 112 - 116, and BH 6 with RN 29 (Date of hire as an RN was 4/22/20).

During an interview on 10/12/20 at 3:30 p.m., with RN 12, RN 12 stated she was a new RN graduate and started working in the ED on 9/6/20, she was still in orientation, and her preceptor was RN 13. RN 12 stated it was her understanding that new graduate RN orientation was eight (8) weeks and she had two more weeks until her orientation was completed. RN 12 stated her regular schedule was three twelve hour shifts per week and two more weeks was not sufficient time for her to be comfortable to independently care for ED patients.

During an interview on 10/12/20 at 4:10 p.m., with RN 13, RN 13 stated she had been employed at the hospital for five years, this was her first job as an RN, and she was currently RN 12's preceptor. RN 13 stated this was the first time in three (3) years she has been assigned as a preceptor, she has been a preceptor only one time previously, three years ago, and the preceptor process for new RN graduates lasted two months. RN 13 stated her experience as a preceptor included, orienting trained and experienced travel (limited employment and considered temporary staff) RN's (generally three day orientation for travel RN's, does not require preceptor training/experience) and this experience qualified her as a preceptor for new RN orientees. RN 13 stated has not received any other preceptor orientation or training.

During an interview on 10/12/20 at 4:45 p.m. with the EDD, the EDD validated RN 13 was RN 12 preceptor and RN 29 was RN 27's preceptor. The EDD stated she was not sure if RN 13 and RN 29 had received preceptor training, the Training Coordinator (TC) was responsible for training preceptors, and she was not sure if RN 13 and RN 29 had been trained as preceptors.
During an interview on 10/13/20 at 2:45 p.m., with the TC, the TC stated she was responsible for conducting preceptor workshops and she was not sure who still worked at the hospital and was on the approved preceptor list. The TC stated human resources keeps track of the approved preceptors and she was not sure if RN 13 and RN 29 were on the approved preceptor list.

During an interview on 10/13/20 at 3:05 p.m. with the HRD, the HRD stated she has not been tracking the preceptor training or which staff were on the approved preceptor list.

During a review of the hospital document titled, "[Hospital 1] Preceptors - ED," undated, indicated there were only five staff members on the approved preceptor list for the ED. Three of the approved preceptor staff were also assigned as clinical coordinators and would not be able to complete both clinical coordinator responsibilities and preceptor training for new graduate, new hire RN's.

During a concurrent interview and record review on 10/14/20 at 2 p.m., with the EDD, the hospital document titled, "[Hospital 1] Preceptors - ED," undated, was reviewed. The document consisted of a list of all ED staff who had taken the preceptor training at some point during their employment. Of that list of 22 RN's, only five RN's were still employed by the hospital. The EDD stated that three of the remaining five are in Clinical Coordinator positions, so would not be able to function in the clinical coordinator role and also act as a preceptor for new graduate, new hire RN's.

During a review of the hospital document titled, " Putting the Pieces Together Preceptor Program," dated 10/13/20, indicated, " ...Preceptor Responsibilities...Collaborate with educator ...Expectations ...works collaboratively with Educator, Director, Orientee, Unit Staff ...Skills Attributes ...Problem-solving & Decision-making skills, Teaching skills, Delegation skills, Coaching skills ...Managerial skills ...Corporate leadership skills, Communication skills ...Behaviors to avoid ...Rush the pace of instruction, Give Assignments or responsibilities beyond orientee's ability ...Preceptor Knowledge Policies & Procedures, Evidenced Based Practice, Documentation, Reality Shock, Resources available, Unit routines, Educational strategies, Adult learning principles ...Preceptor Accountability Individualized teaching to orientee's needs, Complete Orientation Progress Record daily ...Level 3: Competent ...Takes 2-3 years to achieve ...Technical Competence Most familiar element; items usually found on orientation checklists, Psychomotor task that the new employees must perform safely/effectively in order to do the job..."

4. During an interview on 9/10/20 at 12:10 p.m., with the EDD, the EDD stated she recently put together a training class for the triage nurse on the process for assigning the Emergency Severity Index (ESI) (assessing and rating of patients in the ED based on severity or threat of the condition) score. The EDD stated that she had identified the need for this training as soon as she started as director in July. The EDD stated it was an e-learning module she assigned to the staff on 7/29/20, and provided the staff one month to complete the training. The EDD stated in order to qualify to work in triage an RN has to work in their ED for a minimum of one year and has to complete the Triage/ESI training and passed the posttest.

During a concurrent interview and record review on 9/28/20 at 2:30 p.m., with the EDD, a list of the RN staff who had complete the ESI training was reviewed. Fifteen of the ED staff had completed the training so far; it was assigned to the staff two months ago with a month deadline. The EDD stated she was not sure how many RN's had not completed the training that should have. RN staff that have not been here at least one year are not eligible to work in triage so they would not have to complete the training yet. The EDD stated there were some per diem staff and registry staff that work infrequently so they may not have taken it and don't work in triage. The EDD stated there were more than 15 staff that should have taken it.

During a record review on 10/15/20, the documents "ED Daily Room Assignments," indicated on 9/17/20, 9/18/20, 9/23/20, 9/24/20, 9/26/20, and 10/13/20, RN 2 was assigned as the triage nurse and on 10/12/20 and 10/14/20, RN 3 was assigned as triage nurse. Personnel file review completed previously on 10/9/20 (see findings under number one) indicated the hire date for both RN 2 and RN 3 was 11/4/20 making them ineligible to work as the triage nurse. The file review also indicate RN 2 had not completed the basic ESI training required to be completed as part of the ED orientation. Neither RN 2 or RN 3 had taken the ESI competency training or posttest.

A review of the hospital policy "Care of the patient in the Emergency Department: Triage to Discharge," dated 11/19, indicated,"...All patients will have a triage assessment completed by a Registered Nurse [RN], who has obtained triage certification..."

A review of the professional reference, "Emergency Nurses Association (ENA) Position Statement: Triage Qualifications and Competency," dated 2018, indicated, "...It is the position of the Emergency Nurses Association (ENA) that:
1. Triage is a critical assessment process performed by a registered nurse or nurse practitioner with a minimum of one-year of emergency nursing experience, as well as appropriate additional credentials and education that may include certification in emergency nursing and continuing education in trauma, pediatrics, and cardiac care, with verification or certification in those subspecialties as appropriate.
2. Emergency nurses complete a comprehensive, evidence-based triage education course and a clinical orientation with an experienced preceptor to enhance triage knowledge and skills.
3. Triage nurses are engaged in an ongoing triage competency validation process that includes observation and chart review, with remediation and further education as appropriate.
4. Emergency department leadership ensures that registered nurses receive appropriate education and demonstrate the knowledge application and situational awareness required to successfully function in the role of triage nurse according to professional and accreditation standards..."

Based on interview and record review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice when:

1. Registered Nurse (RN) 1 pushed Patient (Pt) 1 onto the ground outside the hospital Emergency Department (ED) and Pt 1 suffered severe head injury. RN 1 did not accurately report the actual sequence of events leading up to Pt 1's injury and hospital staff did not report the abuse and neglect in a timely manner and did not conduct a thorough investigation to determine the root cause of the incident. (Refer to A145 findings 1, 2, 3, 4, 5)

2. Licensed Nurses in the ED did not follow hospital policies and procedures meant to keep patients safe and permitted patients assessed as danger to self to be roomed without first performing safety checks of the room. (Refer to A144 findings 1, 2, 3, 4)

3. Licensed Nurses in the ED were not trained to provide to the needs of patients with behavioral and mental health problems. (refer to A 144 Finding , A 145 finding 6, A1112)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on interview and record review, the hospital failed to ensure adequate number of qualified nursing personnel were available to meet the needs of patients in the emergency department when:

1. Licensed nurses (LNs) did not follow emergency policies and procedures meant to safeguard patients and LNs lacked specialized training to effectively provide services to patients with behavioral and mental problems.

These failures affected four of four patients (Patients 2, 3, 18 and 19) and resulted in the patients either being found in their ED room with ligatures (item used for tying an area of the body tightly) around their neck or the potential for harm. (cross reference A144)

Findings:

During a concurrent interview and record review on 9/10/20 at 4 p.m. with the Quality Risk Specialist (QRS), Pt 3's medical record was reviewed. Review of the ED Physician's (MD 1) documentation, "ED Assessment" dated 8/20/20 at 8:06 p.m., indicated Pt 3 was a 17-year-old brought in by ambulance on 8/20/20 at 6:38 p.m. after being placed on a 5150 hold (Welfare and Institutions code which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for a danger to self (DTS) after attempting to cut her wrists with a piece of glass.

Review of the document "Emergency Department Notes [Nurses' Notes]" dated 8/21/20 at 2:18 a.m. indicated, "...Pt 3 found with bedsheet around neck pulling it tight by security guard...writer [RN 35] notified by guard...Pt 3 instructed [by RN 35] to remove bedsheet from around neck...Pt 3 refusing, stating 'I just want to die' ..."

The QRS stated she was not aware of this incident, there was no incident report completed for this incident, and a review of this incident or RCA (Root Cause Analysis) had not been done to determine how this event could have happened.

During a telephone interview with the Education Coordinator EC on 9/11/20 at 2:30 p.m., the EC stated after having a near-miss event this past May 2020 in the ED involving ligature, all of the nursing staff in ED had been educated about ligature risk within the past few months and 5150 holds. The EC stated the staff should know when and how to check the patient's environment for ligature risks and for other things a patient could use to cause self-harm. The EC stated she had not validated whether the education provided to the staff had resulted in prevention of near-miss events involving ligature or compliance with the policy for frequency of assessment.

During a concurrent interview and record review on 9/11/20 at 3:45 p.m. with the Quality Risk Specialist (QRS), Pt 2's medical record was reviewed. Review of the ED Physician's (MD 2) documentation, "ED Assessment" dated 8/19/20 at 4:13 p.m., indicated Pt 2 was a 16-year-old brought in by ambulance on 8/19/20 at 4:01 p.m. after being placed on a 5150 hold for being a danger to self (DTS).

Review of the documents "Continuous Observation Form" dated 8/19/20 and 8/20/20, indicated on 8/19/20 from 6:15 p.m. to midnight a security guard was providing one to one observation of Pt 2. On 8/20/20 the record indicated from 00:01 until 9 a.m. there was no one to one observation of Pt 2.

Review of the document "Emergency Department Notes" dated 8/20/20 at 04:34 a.m. by RN 1, indicated, "...patient was in bathroom and took shoe laces in attempt to hang himself in bathroom on handrail...patient states he was hearing voices that told him to hang himself...patient moved in front of the nurses' station to be viewed by staff..."
Review of the document "Emergency Department Notes" dated 8/20/20 at 0730 a.m., indicated Pt 2 remained in the ED hallway and there was "no available sitter" to provide one to one observation at that time. RN 25 indicated "Hourly observation documented."
The QRS verified there was no documentation by nursing staff from 8/20/20 at 00:26 until 8/20/20 at 4:34 a.m., no assessment of Pt 2's neck, and no notification to the physician regarding Pt 2's attempt to hang himself, notification of Pt 2's parent regarding this incident, or any other documentation regarding this event.

The QRS stated she was not aware of this incident, an incident report was not submitted about this occurrence, and a review of this incident or RCA (Root Cause Analysis) had not been done to determine how this event could have happened. The QRS stated when an incident report is submitted electronically it is routed to the quality/risk department and the director of the nursing unit will get notified at the same time so they would be able to start their investigation.

During a concurrent interview and record review on 9/11/20 at 4:15 p.m. with the QRS, Pt 18's medical record was reviewed. A review of the document "Patient Summary Report" indicated Pt 18 was brought in by ambulance on 9/9/20 at 9:05 p.m. after attempting suicide by medication overdose. QRS stated Pt 18 was placed on a 5150 hold for being a danger to self.
The clinical record indicated Pt 18 remained on a gurney in the hallway on a monitor and with an IV in place. At 1:17 a.m. an "Environmental Risk Assessment" was completed by RN 38, and all identified risks for self -harm were removed from the "room" (hallway) except a bra and shoelaces. RN 38 indicated all cords and IV poles were removed. The record indicated Pt 18 remained on a gurney in the hallway until around 3:30 a.m. when she was moved to an ED room. The QRS verified there was no Environmental Risk Assessment of the ED room where Patient 18 was moved to.

During a concurrent interview and record review on 9/11/20 at 4:40 p.m. with the QRS, Pt 19's medical record was reviewed. A review of the document "Patient Summary Report" indicated Pt 19 was brought in by ambulance on 8/22/20 at 10:18 a.m. on a 5150 hold for being a danger to self. The record indicated Pt 19 remained in ED on an involuntary hold from 8/22/20 until 9/2/20 when Pt 19 was transferred to another facility for acute psychiatric care. A review of the documents "Ligature Risk Assessment" for the entire hospital stay indicated the assessment was completed once each day for 8/22, 8/23, 8/25, 8/26, 8/27, 8/28, 8/31, 9/1 and 9/2; it was not completed on 8/24, 8/29, and 8/30. Review of the document "Suicide Risk Assessment" for the entire hospital stay indicated, the Suicide Risk Assessment was completed once each day on 8/22, 8/23, 8/25, 8/26, 8/27, 8/28, 8/29, 9/1, and 9/2; it was not completed on 8/24, 8/30, 8/31. The QRS stated the Ligature Risk Assessment and the Suicide Risk Assessments are supposed to be completed once each shift (12-hour shift).
During an interview with the Chief Nursing Officer and the Emergency Department Director (EDD) on 9/11/20 at 5:30 p.m., the findings from the record review of Pt 2 and Pt 3 were discussed. The EDD stated the nursing staff had received training on ligature risks within the past couple of months prior to these events and should have removed the ligatures risks (the sheets and the shoelaces). The EDD stated the nurses should not have documented the removal of those items when they did not remove them. The EDD stated patients here on a 5150 hold should be observed at all times and not left alone in the bathroom where they can hurt themselves. The EDD stated it is her expectation that the staff complete the ligature risk assessment every shift per policy as well as the suicide risk assessment. The CNO stated the security guard company has had some difficulty providing enough coverage for the number of patients needing one to one continuous observation. The EDD stated the environmental risk assessment should be done as soon as possible after a patient arrives and if a patient is moved to a different room then a risk assessment of the new room needs to be done.

During a telephone interview on 9/15/20 at 12:29 p.m. with ED RN Clinical Coordinator (RN 11), stated more training for staff needs to be done regarding care of patients with mental illness. RN 11 stated they have not been given any education or training on the standard of care for adolescent patients with mental health issues and behaviors. RN 11 stated the ED needs more staff to take care of patients with high acuity who need closer observation, and there is a shortage of security guards to stay with patients who need one to one continuous observation. RN 11 stated for patient on a 5150 the room should be checked for anything the patient can use to harm themselves before the patient gets to the room. RN 11 stated when the patient gets into the room their belongings including shoes should be secured in the patient locker. RN 11 stated patients on a 5150 are not supposed to be left alone in the bathroom.
During a concurrent interview and record review with RN 1 on 9/23/20 at 1:45 p.m., Pt 2's "Emergency Department Notes" dated 8/20/20 at 4:34 a.m. were reviewed. RN 1 verified he was the author of that note although he was not the RN assigned to care for Pt 2. RN 1 stated he has no previous experience caring for psychiatric patients, and no education about the standard of care for patients with mental health conditions. RN 1 stated he has not had any education or training about taking care of adolescents. RN 1 stated he got about one day of orientation in the ED when he started there, even though when he was hired he was told he would get three months of training.

A review of the facility policy and procedure, " 5150 Holds and Behavioral Emergencies", dated 12/19, indicated, " ...The ligature risk assessment must be completed once every shift ...Patients on a 5150 hold for being a danger to self (DTS) or non-5150 suicidal patients must have a sitter/guard in the room at all times ...Patients who are a danger to others (DTO) or violent must have a security guard assigned ...the security guard must be able to visualize and have immediate physical access to the patient the entire time they are assigned to the patient ...Patients must be observed at all times ...Patients cannot be taken to a private restroom and left alone ...Patients may use the bedside commode or be escorted to the restroom with the staff in attendance in the restroom ..."