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Based on staff interview, facility policy and procedure, and medical record review the facility failed to ensure RNs (registered nurse) supervise the nursing care for all patients, evaluate patient care needs, patient health status, and patient response to interventions. This deficient practice can potentially effect all patients receiving treatment at this facility.

Findings include:

The facility failed to monitor patient care needs, adjust treatment plans/goals according to patient change in condition, assess vital signs, perform physical assessment, assess health status, provide life saving interventions, and evaluating patient response to interventions.


The cumulative effect of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility. See A395

Based on medical record review, policy and procedures, and staff interview the facility failed to ensure the RN (registered nurse) assessed, provided interventions, and evaluated patient care needs in 1 of 10 medical records reviewed. This can potentially affect all patients receiving treatment at this facility.

During the complaint survey from 8/8/12 to 8/10/12 reviewed the following facility policies:

Policy: "Vital signs and Measurement of Patient's Height and Weight" last revised 1/26/07:

I. Standard of Care: The patient can expect that vital signs, the measurement of a patient's temperature, pulse, respirations, blood pressure, height and weight will be taken for the purpose of establishing a baseline and then as a means to monitor for changes in physiological status. Pulse oximetry should be considered a vital sign in situations where accurate assessment and monitoring is critical.

II. When to Monitor Vital signs:
A. Admission
1. Acute adult: Monitor vital signs BID (twice daily) x 3 days after admission to the hospital..
C. Additional indications for vital sign monitoring:
1. Medical staff order (including monitoring because of; need for orthostatics, abnormalities detected during baseline monitoring; physiological status; an active or ongoing medical problem, etc)
2. Medication related indications for vital sign monitoring
3. As clinically indicated: change of condition, return from stay at other facility, etc.
V. Vital Signs: What to document and Report:
B. RN Reporting and Documentation of Abnormal Vital signs:
1. Assess the patient with abnormal vital signs and document patient status in medical record;
2. Determine if change in vital signs is a change in condition for patient;
3. Notify physician of pertinent findings;
4. Initiate appropriate interventions/therapies and revise treatment plan as indicated.
C. Refusal of vital signs: the RN will document refusals, educate patient as needed
and make ongoing attempts to obtain vital signs.
D. Document all vital signs (including refusals) on the Vital Signs/Weight Flow Sheet
E. Incorporate vital signs monitoring into Treatment Plan whenever vital signs are indicated more frequently then routine monitoring.

Recommended Abnormal Ranges:
Systolic Blood Pressure: <100
Diastolic Blood Pressure: <60
PO2 (pulse oxygenation): < 95%

Policy: "Physical Assessment" NS# 211 "P" last revised 5/2010:
II. Policy
The patient can expect:
1. Ongoing evaluation of health care status, including physical assessment;
2. the nurse to utilize health assessment data to develop a recovery/care plan
goals and interventions specific to patient medical needs/problems;
3. Ongoing assessment, planning, implementation, and evaluating
effectiveness of treatment to restore or maintain health and prevent illness
III. Physical Assessment Screen
A. RN's in all inpatient programs will complete a physical assessment screen for:
1. New admissions: completed within 8 hours of admission
2. Patient change in condition

Policy: "Behavior Observation Status" MS 3.1.6.12 NS #207 "B" last reviewed 3/10/2004.
II. Intervention
A. A patient identified as requiring behavior/safety monitoring shall be placed on an appropriate observation status by the medical staff or RN.
B. Medical staff will write an order or give a verbal telephone order for either 1:1 or
15 minute behavior observation monitoring.
F. The RN will communicate specific direction/information related to patient's
behavior and the indication for the monitoring to unit staff .
G. The RN will initiate Behavior Observation flow sheet
H. The RN will document the behavior to be observed and corresponding
precautions on the Behavioral Observation Flow Sheet.
I. The RN is accountable to ensure completion of observation monitoring and
documentation by delegated staff.
K. RN will review and sign the Behavioral Observation Flow Sheet each shift.

Policy: "Code 4--Medical & Nursing Care of the Patient With a Medical or Life-Threatening Emergency" Last revised 10/2011:

1. A Code 4 Medical Emergency will be initiated by any Milwaukee County Behavioral Health Division(MCBHD) staff member recognizing a medical or life- threatening emergency.
2. A Code 4 must be called anytime a patient's level of care requires the paramedics to be summoned to MCBHD.

Per review of Pt #1's medical record on 8/8/12 beginning at 1:55 PM, on 7/24/12 at 1:58 PM Pt #1 was brought to the PCS (Psychiatric Crisis Service) by the Milwaukee Police Department after calling 911 from home and asking to talk to the President. Pt #1 had not taken medication for Bipolar disorder for one week. Pt #1 has a history of sleep apnea and has CPAP (continuous positive airway pressure) machine at home. Per Seclusion/Restraint Physician Order Form dated 7/24/12 and signed at 4:15 PM, order for 4 point restraints (all 4 limbs), reason due to "patient exhibiting violent or self destructive behavior that jeopardizes the immediate physical safety of the patient." PCS RN's progress note timed 4:50 PM states, "Pt agitated and threatening staff..pt continues to yell". Review of the Assessment and Progress Record for Seclusion/Restraint dated 7/24/12 reveals documentation of Pt #1 receiving Geodon 20 mg intramuscular (antipsychotic) and Benadryl 50 mg intramuscular (antihistamine) at 4:20 PM, Haldol 10 mg (antipsychotic) and Ativan 2 mg (benzodiazepine) at 5:10 PM. PCS RN's note at 5:43 PM states, "Pt asleep in restraints. Pt assisted out of restraints."
Review of the PCS Assessment and Progress Record For Seclusion/Restraint shows no documentation of staff monitoring Pt #1's vital signs including blood pressure, pulse, pulse oximetry, and respiratory rate when Pt #1 showed visible signs of sedation after receiving doses of antipsychotic, benzodiazepines, and anithitamine medication injections.

Per review of RN H (Pt #1's assigned nurse) admission note dated 7/24/12 at 7:55 PM, Pt #1 was admitted to 43 A from PCS at 6:15 PM. RN H documented, "order obtained for pt to sleep in chair due to size and breathing issues due to morbid obesity." Review of Vital Signs Flow Sheet reveals no documentation of admission vital signs including temperature, pulse, respiratory rate, blood pressure, and pulse oximetry. Review of Pt #1's medical record shows nursing admission physical assessment not done until 7/25/12 at 10:45 am more than 15 hours later. This practice is inconsistent with the facility policy for vital sign monitoring and physical assessment and does not provide appropriate monitoring of Pt #1's "breathing issues".

Review of RN F's progress note dated 7/24/12 timed 10:45 PM - 11:15 PM states, "Noticed Pt having periods of sleep apnea while sitting in geriatric chair by nurses station. Pt pale, pulse 75, Pox (pulse oximetry) 77% on room air...Pt unresponsive...Dr notified and updated that pt was having 25 seconds periods of apnea(not breathing) then 3 rapid gasps of loud breathing, skin was cool and pale, pulse oximetry on room air was 67% when apneic and 88%-90% when took 3 breaths." Per RN F's progress note telephone was given to RN H to speak with the PCS physician and RN H notified physician of current vital signs as follows: Blood pressure of 95/53 and pulse ox 71% on room air at 11:05 PM. Per medical record review no documentation of additional physician orders given at this time. Pt #1's vital signs taken at 11:15 PM were documented as follows: Blood Pressure 79/45, pulse 67, Pox 83% on room air. No other vital signs are documented after 11:15 PM.

Progress note dated 7/25/12 at 1:00 am reveals Pt #1 was sent out via ambulance to West Allis Memorial Emergency Department. Review of the medical record reveals 1 hour and 45 minutes from the last vital sign documented until the patient was sent out via ambulance to the ER.
Pt #1's blood pressure and pulse oximetry are substantially below recommended abnormal values as stated in the Vital sign policy, Pt #1 has a decreased level of consciousness and 25 seconds periods without breathing. Review of the medical record reveals no evidence or documentation of a comprehensive nursing physical assessment, nursing interventions, or evaluations provided in response to Pt #1's abnormal vital signs and decreased level of consciousness between arriving on the unit at 6:15 PM and 1:00 am when transported to ER. Review of Pt #1's medical record reveals no documentation or evidence of initiating a Code 4, this is not consistent with facility Code 4 policy which requires a Code 4 be called "anytime a patients level of care requires the paramedics to be summoned to MCBHD."

Per interview with DON(Director of Nursing) D on 8/9/12 beginning at 8:30 am, when asked by surveyor what is expected of staff when a patient presents in the condition described in Pt #1's medical record, DON D responded, "I probably would call a code if patient is unresponsive with a Pox in the 60's and 70's."

Per interview with Medical Director B on 8/9/12 beginning at 9:25 am, when asked by surveyor what is expected of staff when a patient presents in the condition described in Pt #1's medical record, Medical Director B responded staff should call a code and would expect oxygen to be applied and actions to be documented in the progress notes.

Per interview with Medical Doctor E on 8/9/12 beginning at 9:45 am, when asked by surveyor what is expected of staff when a patient presents in the condition described in Pt #1's medical record, Medical Doctor E stated, "generally staff should call a code if pulse oximetry is that low."

Per telephone interview with RN F on 8/9/2012 beginning at 11:00 am, RN F was not Pt #1's assigned nurse, but observed pt #1 heavily sedated in a geriatric chair next to the nurses station. RN F stated pt #1 seemed to be getting worse as the evening went on. Per RN F Pt #1 was unresponsive and having 25 second periods of apnea (not breathing). RN F stated she did not see RN H (Pt #1's assigned nurse) check vital signs or perform physical assessment when patient arrived on the unit. RN F stated Pt #1 was not responding to verbal stimuli. Per RN F at approximately 10:45 PM, checked Pt #1's vital signs and pulse ox was 77 percent on room air, RN F informed RN G (Administrative Resource RN) of Pt #1's condition. RN F then stated, "patient needs to go to the hospital now". RN G responded, "no he does not need to go, this is normal for patients with sleep apnea". When asked by surveyor if a code was called, RN F responded, "no (RN G) told us not to". When asked by surveyor if oxygen was provided to pt #1, RN F responded, "No, RN G said oxygen will not help; he needs forced air". Per RN F PCS physician contacted and informed of pt #1's vital signs and physician stated will call unit back; no additional orders given. When asked by surveyor what was done for Pt #1 between 10:45 PM and the end of RN F's shift (12:00 am), RN F stated, "we just kept checking vital signs."

Per telephone interview with RN H (Pt #1's assigned nurse) on 8/9/12 beginning at 1:30 PM, RN H stated Pt #1 was admitted to the unit on 7/24/12 at approximately 6:15 PM. RN H stated Pt #1 was in a geri chair "completely asleep" next to the nurses station. When asked by surveyor if RN H obtained Pt #1's vital signs or performed admission nursing assessment upon arrival to the unit, RN H responded, "no, patient was sleeping". Per RN H Pt #1 kept at nurses station to monitor breathing, Pt #1 would have 10-15 second periods of apnea (not breathing) which progressed to 25 second periods of apnea around 10:30 PM. Per RN H, checked Pt #1's vitals at approximately 10:45 PM and informed RN G of Pt #1's condition, RN G did not feel it was appropriate to call a code and did not feel giving Pt #1 oxygen would help due to history of sleep apnea. RN H did not provide oxygen or initiate a code 4. When asked by surveyor what nursing assessments and interventions were provided to Pt #1, RN H stated, "I rolled up a towel and placed it behind (Pt #1's) neck to keep his head up and checked (Pt #1's) vital signs".

Per interview with RN G on 8/9/12 beginning at 4:00 PM, RN G worked second shift as the Administrative Resource RN of MCBHD on 7/27/12. Per RN G, made rounds on PCS and was informed Pt #1 was going to be admitted to inpatient unit. RN G observed Pt #1's breathing issues in PCS and was concerned because of Pt #1's size (6' 8" 383 lbs). Spoke with PCS RN P, and stated staff needs to watch Pt #1 closely and check Pox, Pt #1 needs to be transported in Geriatric chair. At approximately 10:00 PM, RN G was informed of Pt #1's condition on the inpatient unit. RN G arrived on unit and witnessed Pt #1 sleeping in geri chair, RN G placed rolled up towel behind Pt #1's head to keep head up. RN G placed continuous pulse ox on Pt #1 and pulse ox was 78% on room air. Per RN G assessed Pt #1 at this time, however did not document assessment. When asked by surveyor if Pt #1 was alert and oriented, RN G stated, "No, (Pt #1) maybe opened eyes to name for a few seconds." Per interview, RN G did not feel it was necessary to call a code or provide oxygen; informed RN H (Pt #1's assigned) to contact PCS. When asked by surveyor if RN G would call a code if Pt #1's pulse ox was 67%, RN G responded, "I would have freaked out, I absolutely would have called a code." Per RN G, not aware Pt #1's pulse ox dropped to 67%.
RN H waited approximately 4 1/2 hours to check Pt #1's vital signs, while Pt #1 sat in chair at the nurses stations heavily sedated, unresponsive, with 10-25 second periods of apnea. No documentation or evidence of a comprehensive nursing physical assessment, interventions, or evaluations provided to Pt #1 between arriving to the unit on 7/24/12 at 6:15 PM and being transported to ER via ambulance on 7/25/12 at approximately 1:00 am.

Per review of Aurora West Allis Emergency Department records dated 7/25/12, ER Physician's Clinical Impression was documented as follows: "Diagnoses of Sleep Apnea and hypoxia were pertinent to this visit, hypoxia secondary to sedative medication, Pt to be transferred back to PCS in stable condition."

Review of the physician to physician transfer communication form entitled "Request for Referral/Transfer to PCS" dated 7/25/12 timed 5:00 am, reveals conditions must be met before pt #1 can be transferred back to MCBHD from West Allis Memorial ER. Documentation signed by Physician N states Pt #1 must have a bariatric bed and CPAP machine provided in order to be accepted back to MCBHD. Current Problem--"Sat (oxygen saturation) dropped on inpatient unit, probable sleep apnea.." Current Vitals O2 Sat 98% on room air when awake.

Per record review Pt #1 returned back to MCBHD from West Allis Memorial Emergency Department on 7/25/12 at approximately 10:45 am.

Physician order dated 7/25/12 at 11:30 am to "Begin CPAP at 12 cm H20"

RN progress note dated 7/25/12 at 9:00 PM states CPAP machine brought to unit, properly fitted on Pt #1 and set by staff per specified orders.

RN progress note dated 7/25/12 at 10:15 PM states CPAP machine is set up for Pt #1 and Pt #1 is "very knowledgeable about the use of the CPAP machine"

Review of Nursing Assessment Flow sheets and progress notes reveals the following documentation of Pt #1's Respiratory status:
7/25/12 10:45 am--"Standard Met"
7/25/12 9:00 PM--"SOB (Shortness of Breath) with activity"
7/26/12 10:15 am--"SOB upon exertion"
7/26/12 10:35 PM-- "Labored" (breathing); "SOB with activity"
7/27/12 6:00 am--"SOB noted"
7/27/12 11:42 am--abnormal Pox 93%-94% on room air, "wakeful apnea noted while awake on unit"
7/27/12 4:30 PM--Pox 90%.
7/27/12 5:30 PM--Psychologist progress note states, "(Pt #1) having significant difficulty breathing today".
7/27/12 7:45 PM--"Labored" and "SOB". RN O's progress notes states, "less loud and irritable tonight, cooperative with scheduled meds, though Cogentin IM appeared to have little effect on labored breathing." "...appears to request fluids excessively, this may be due to his heavy mouth breathing and resulting dryness. I gave him ice chips to ease his mouth dryness.." "(Pt #1) has made attempts to lie down with CPAP machine and rest but he becomes frightened and gets up again".

Per interview with Medical Director B on 8/9/12 beginning at 9:25 am, Pt #1 was complaining of dry mouth and difficulty swallowing (documented by Medical Director B on 7/27/12 at 3:30 PM). Per interview Medical Director B attributed symptoms to Latuda, an antipsychotic medication prescribed on 7/25/12. Medical Director B stated this medication was discontinued on 7/27/12 and Pt #1 was started on Cogentin to decrease the side effects of the antipsychotic medication.

Despite Pt #1 being transferred and treated in the ED on 7/25/12 due to hypoxia (low oxygen level) and sleep apnea, review of Vital Signs flow sheet reveals no documentation or evidence of nursing staff adjusting treatment plan and monitoring Pt #1's respiratory status via pulse oximetry upon Pt #1's return on 7/25/12 or 7/26/12. On 7/27/12 staff documented Pt #1 having shortness of breath, labored breathing, abnormal Pulse oximetry readings, and periods of apnea, however there is no documentation or evidence of nursing staff notifying the physician of findings or providing more frequent monitoring, nursing interventions, or evaluations of Pt #1's respiratory status.

On 7/27/12 at 8:30 PM, RN O's progress note states, "Pt has broken the new face mask obtained today (CPAP mask), he may be yanking it off his face and it breaks where the hose connects to the mask." Per RN O's note, "elevated the head of his bed and had him lay on his side, contacted Omnicare and ordered another mask" Per RN O's note Omnicare was going to try to drop off another mask that night. Per review of medical records no documentation or evidence of Pt #1 receiving or applying new facemask for the CPAP machine.

7/27/12 at 5:00 am, RN J's "Death Note" states, "Called for code 4 about 3:30 am, writer arrived pt had been found unresponsive, no pulse or resp (respirations),CPR had already been initiated. Paramedics called--CPR continued." Pt #1 was pronounced dead at 4:04 am.

Per interview with CNA I on 8/9/12 at 12:30 PM, CNA I shift started at 11:00 PM on 7/27/12, CNA I began patient rounds at 11:30 am. CNA I stated 30 minute checks were being conducted on Pt #1. CNA I stated Pt #1 was last checked at 2:30 am and was asleep snoring loudly, CNA I noticed Pt #1 would snore then stop for a period of time. Then at approximately 3:05 am CNA I found Pt #1 lying on back in bed not breathing. CNA I stated knew something was wrong because Pt #1 was no longer snoring, CNA I placed finger under Pt #1's nose and was unable to feel expirations. CNA I then yelled for RN J. RN J arrived in the room with CNA L. RN J checked for pulse and then used stethoscope to check for breathing. CNA I is not CPR certified. RN J sent CNA L to call 911 and RN J left the room to call a Code. Per CNA I does not recall RN J starting CPR, CNA I and RN J waited for the code team to come. Per CNA I this took approximately 2 minutes. CNA I stated someone did show up earlier with new CPAP mask and placed it on the counter, however Pt #1 did not have mask on during night rounds.

Per review of Medical staff order form dated 7/24/12 signed 3:30 PM, physician order for Pt #1 to be on 15 minute behavior observations rounds on the night shift. Per night shift environmental round documentation dated 7/25/12, 7/26/12, and 7/27/12 between 11:00 PM and 6:30 am, and per interview with CNA I, staff was rounding on Pt #1 every 30 minutes and not every 15 minutes as required by the physician order.

Interview with RN J on 8/9/12 beginning at 12:45 PM, revealed on 7/27/12 RN J started night shift at 11:00 PM. RN J stated new CPAP mask did arrive, but Pt #1 was sleeping so RN J did not place it on Pt #1. Per RN J called in Pt #1's room by CNA I and found Pt #1 pulseless and not breathing. Per RN J applied AED and initiated CPR and instructed CNA L to call a code.

Per interview with CNA L on 8/10/12 beginning at 10:45 am, CNA L's shift started at 11:00 PM on 7/27/12. Per CNA L over heard CNA I yelling for the nurse, so CNA L also responded to provide assistance. CNA L stated RN J and CNA L arrived in the room to find Pt #1 lying in the bed pulseless and not breathing. CNA L stated both RN J and CNA L left Pt #1's room, RN J instructed CNA L to call 911, while RN J went to the nurses station to call a code. Per CNA L, CNA I stayed in the room with Pt #1. RN J and CNA L then went back into Pt #1's room. CNA L was unsure if RN J started CPR, Per CNA L thinks RN J was pressing on Pt #1's chest, however was calling out Pt #1's name.

Per interviews with CNA I and CNA L, RN J left the patient to call a code instead of immediately beginning CPR and both were unable to confirm if RN J provided CPR prior to the code team arriving.

Per interview with Dir A and QI C facility on 8/10/12 at approximately 12:30 PM, RN J was re-educated on CPR and Code 4 policy due to the MCBHD's review of Pt #1's death. Training not provided to all staff.

Review Pt #1's medical record revealed Pt #1 had visible signs of respiratory issues not monitored or addressed by staff which resulted in a visit to the ER on 7/25/12 due to hypoxia, sedation, and sleep apnea. Pt arrived back to unit and nursing staff did not provide additional monitoring of Pt #1's respiratory status based on recent history. Staff Documentation on 7/27/12 of Pt #1 experiencing increased difficulty breathing, no additional monitoring put in place to ensure patient safety. Pt #1 was not being monitored for behavioral checks every 15 minutes as required. CNA I witnessed Pt #1 snoring with periods of apnea (not breathing) on the night of 7/27/12; nursing staff did not provide patient with needed CPAP on the night of 7/27/12 due to patient sleeping.

Per Dir A on 8/10/12 Medical Examiner's final report on Pt #1's cause of death had not yet been released.

The above medical record findings were confirmed with Dir A, Medical Director B, QI C, DON D, and Medical Doctor E on 8/9/12 beginning at 8:30 am.