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Based on interview and documentation review, the facility had failed to provide adequate nursing services (Condition) and failed to ensure nursing staff would reassess patients when their health conditions changed (Immediate Jeopardy).

Finding include:

IMMEDIATE JEOPARDY

An unexpected death at the facility had occurred 04/04/10, with a resultant complaint (#NV00025078) investigation being initiated 04/16/10. The facility did not have documentation to indicate that nursing staff would conduct reassessments of patients whenever the patients' health conditions changed, resulting in an immediate jeopardy declaration at approximately 4:30 PM.

Note: At approximately 5:30 PM the immediate jeopardy was abated when the facility's corrective action plan was returned and included directions to nursing staff to reassess a patient whenever the patient's health condition changes and that the facility would implement training of their plan with the nursing staff as soon as practicable (with current shift staff and other shift staff as they arrive to work).

CONDITION LEVEL CITATION

Interviews with the staff on duty during the time of incident, observations, document and clinical record review, the following processes were not in place as identified at:

CFR 482.23(b)(3) Rn Supervision Of Nursing Care (Tag A395)

Based on observation, interview and record review, the facility failed to ensure nursing and psychiatric staff monitored and evaluated upon change of condition the care and health status for Patient #1.

Findings include:

Patient #1 was admitted to the facility on 3/30/10, under a Legal 2000 (State of Nevada's Involuntary Civil Commitment Process) from an acute care facility. Her diagnosis on admission were bipolar 1 disorder, most recent episode manic severe with psychotic features, morbid obesity, tachycardia and hypertension.

Patient #1 was admitted to the psychiatric observation unit (POU) and later transferred to the AB unit on 3/31/10, where she was found deceased on the morning of 4/4/10, during on one-to-one staff patient observations (referred to as 1:1).

Record Review

According to Patient #1's discharge summary she was extremely agitated from the moment the patient arrived on the unit. The patient was medicated with oral and intramuscular medications (IM) for agitation and aggression. The medication administration record (MAR) indicated Patient #1 received both oral and IM doses of Haldol, Ativan, Benadryl, Thorazine, Geodon and Cogentin during the patient's admission to the facility. On 4/3/10, Patient #1 received a total dose of 6 milligrams (mg) of Ativan, 250 mg of Benadryl, 30 mg of Haldol and 100 mg of Thorazine IM.

On 4/1/10, at 8:10 AM, the physician wrote an order for one-to-one (1:1) observation and for no other patient to be admitted into the patient's bedroom due to bizarre and severe agitation towards others. Documentation indicated the patient remained on 1:1 observation until the patient's death.

Review of the progress notes, dated 4/4/10, at 5:20 AM, indicated the patient was observed to be unresponsive, not breathing and cyanotic. A faint radial pulse was documented as felt and cardio-pulmonary resuscitation (CPR) was started. The notes documented the paramedics arrived and indicated the patient was in asystole and the CPR was stopped. The police and coroner's office was notified.

The discharge summary for Patient #1 indicated on 4/4/10, around 5:15 AM - 5:30 AM, Patient #1 was found not breathing and unresponsive, cyanotic, lying in the prone position on the floor. The notes indicated it was questionable whether the patient had a pulse at that point. According to reports by the nurses, cardiopulmonary resuscitation (CPR) was given and the paramedics were called, but eventually the patient was pronounced dead.

A review of the Special Observation of Patients policy, dated 12/9/08, was reviewed. The definition of 1:1 observation documented, "The Charge Nurse/MHT4 (Mental Health Technician 4) assigns a specific staff member, in writing, to maintain continuous, uninterrupted visual contact and close physical proximity to the patient. These staff members do not engage in any activities that could distract the staff member from performing patient surveillance. Staff members do not allow patients to take blankets, towels, sheets or any items that may cause harm into the bathroom. The Charge Nurse may restrict off unit privileges based on nursing assessment."

The policy revealed the assigned staff member was to record routine observations every 15 minutes. The patient's room door was to remain partially open and the staff was to remain in attendance just outside of the door. Continuous monitoring of the patient (both auditory and visual) was to be maintained even when the patient was asleep.

The Observation Check Form, dated 4/4/10, for Patient #1 was documented that she was checked every 15 minutes from 12 AM to 5:30 AM. The form indicates to code and initial every 15 minutes. The code documented patient laying on the floor from 12 AM to 5:30 AM. There was no documentation that vital signs were checked. However, space was available on the form for recording staff actions.

Interviews

On 4/16/10 at 3:10 PM, Employee #1 was interviewed in the facility conference room. Employee #1 indicated that Patient #1 was a 53 year-old female in from California for a conference. The employee indicated when the patient was at the casino she apparently became disorganized. He indicated the patient was taken to Sunrise Medical Center and than came to us (Southern Nevada Adult Mental Health Services) on the 30th of March.

Employee #1 further indicated that Patient #1 since arriving was displaying extreme agitation, disrobing and aggression. Employee #1 indicated the facility increased her dose of Depakote and she required the use of seclusion and restraints to maintain the patient's safety and the safety of other patients.

Employee #1 mentioned that the resident's last restraint and seclusion was "...at least 36 hours..." previous to her death. Employee #1 indicated on 4/3/10 at 10:30 AM, dosing of Patient #1 began due to behaviors, and at 2:30 PM on the 4/3/10, was the last dose.

At 3:30 PM on 04/16/10, both surveyors conducted a walk-through of AB Unit to look at the unit and where Patient #1's bedroom was located on the unit. While on the unit an interview was conducted with Employee #2 at 3:35 PM on 4/16/10.

Employee #2 mentioned that doors should not be closed, but indicated if they are the 1:1 staff would need to be inside so they are in close proximity to the patient. Employee #2 further indicated that 1:1 used to mean arms-length of the patient. The employee indicated the policy now states in "...close proximity." Employee #2 indicated that being on a 1:1 means your whole assignment and responsibility is the patient on that 1:1.

Employee #2 indicated that the facility does not use chemical restraints, "We treat the behaviors." She stated, "If anyone gives medications to treat behaviors than they better get vitals or at some point arouse the patient to get a response."

On 4/16/10 at 4:30 PM, Employee #3 was interviewed and indicated that she was the 1:1 for Patient #1 from 11:30 PM till 3:00 AM, and 4:00 AM till 5:00 AM during the night shift on 4/3/10 and 4/4/10. She stated, "Employee #4 took over for me at 3:00 AM so I could take my break."

Employee #3 explained that the policy for 1:1 was in "...close proximity" and the old policy was at "...arms length." She indicated she sat right outside the door and the door was closed. The employee indicated that she was able to view Patient #1 through the window in the door. She indicated during the first few hours of her scheduled 1:1 the patient was observed "Snoring" and "Passing gas," and moans could be heard.

Employee #3 further mentioned that at 3:00 AM she was scheduled to go to dinner and Employee #4 relieved her and he was to conduct the 1:1 from 3:00 AM till 4:00 AM, upon her return. While on her break, she observed Employee #7 in her car with the engine running. Then mentioned she did not see Employee #7 till around 4:25 AM. She stated, "I'm sure Employee #7 was scheduled for B side, but after her break she was sitting on the A side."

She indicated that once she returned, Employee #5 informed her that Employee #4 left around 3:14 AM and was gone for awhile, and asked her to watch the patient until he got back from the restroom.

Employee #3 indicated that she also mentioned to her that she had to have Employee #6 (charge nurse) look in on the patient because something wasn't right when she took over for Employee #4. She indicated Employee #6 just looked at her and did not arouse her in any way, and did not "Touch her," or "Shake her." There was no documentation in the clinical record Employee #6 assessed Patient 1 at the time of her change of condition.

Employee #3 was asked if at any time was the patient's vitals taken or was she thoroughly assessed during her 1:1 times. She indicated that no attempts to take vitals were initiated. She had no direction from the nurses to take the vitals of Patient #1. She did not observe any nurses enter the room to assess the patient during her 1:1 time with the patient. She indicated the only time she was aware of a nurse entering the room of patient #1 was with Employee #5 while she was on dinner break.

During her second 1:1 shift from 4:00 AM till 5:00 AM, Employee #3 indicated that the patient was still making sounds from her mouth and she was lying on her left side facing towards the door. By 4:30 AM, she indicated the patient was lying on her stomach.

Employee #3 was asked about what occurred at the time of the change of condition was discovered. She indicated she observed Employee #7 was doing chest compressions and Employee #6 was initiating the use of the Ambu Bag. The employee indicated she noticed the patient had oxygen on and Employee #7 placed a pulse/oxy device on the patient.

Employee #3 further indicated that she remembered seeing the AED (Automatic External Defibrillator) machine there and was sure that it was not utilized during the code. She finished by indicating Patient #1 was turned over, she had "Salvia" coming from her mouth and "Blood" on her nose.

Employee #3 was asked one last question about the appearance of Patient #1 when they turned her and if she was flaccid or appeared more rigid. She indicated that the patient's arms were up and her hands by her face and she appeared more "stiff."

On 4/26/10 at 10:54 AM a telephonic interview was conducted with Employee #4.
Employee #4 was interviewed about what his duties were for the night shift covering the hours of 11:00 PM on 4/3/10 through the end of shift in the morning of 4/4/10. The employee indicated he was responsible for the monitoring board from 11:00 PM till 3:00 AM. He described the monitoring board duties as doing unit rounds to locate and record observations of patients at varying time intervals.

Employee #4 indicated at 3:00 AM, Employee #5 took over the monitoring board as he relieved Employee #3 for her break and conducted the 1:1 from 3:00 AM till 4:00 AM. He mentioned at approximately 3:15 AM he needed to go to the restroom and asked Employee #5 to monitor the 1:1 until he got back.

Employee #4 was asked to describe what the patient was doing during his 1:1 time. He indicated that, "She appeared to be sleeping." He denied hearing moans, snoring or the passing of flatus, and indicated she was lying on her stomach.

Employee #4 was asked about his return from the restroom. He indicated he returned around 3:30 AM from the restroom. Once he returned back to the patient ' s room, Employee #5 informed him that when she relieved him for his bathroom break, she checked on the patient and noticed the patient wasn't breathing right and retrieved Employee #6 to assess the patient.

Employee #4 was asked if he had entered the room of Patient #1 during his 1:1 time. The employee indicated at no time did he enter the room to assess if she was breathing, take vitals or nudge her to observe a physical response. He added at no time did he observe a nurse enter the room to assess the patient during his 1:1 time or during his time on the monitoring board.

On 4/26/10 at 1:59 PM a telephonic interview was conducted with Employee #5. Employee #5 was asked to describe her duties during her night shift that covered from 11:00 PM on 4/3/10, till end of shift 4/4/10. Employee #5 indicated she was responsible for the monitoring board from 3:00 AM till 5:00 AM. Employee #5 indicated at 5:00 AM till 7:00 AM or so, she was responsible for the 1:1 for Patient #1.

Employee #5 was asked about her relief of a bathroom break for Employee #4. Employee #5 indicated that Employee #4 relieved Employee #3 at 3:00 AM so she could go on her dinner break. Employee #5 indicated at approximately 3:15 AM, she observed Employee #4 leave the nursing desk and not from the patient's door or room, headed towards her to ask if she could relieve him for a bathroom break. Employee #5 indicated immediately after she was approached, she headed to the patient's room, opened the door and entered. She indicated that she called the patient's name a couple of times; not getting a response, then looked at the nurse's station and could not locate a nurse. However, she located Employee #6 on the "A" unit.

Employee #5 further indicated that Employee #6 proceeded to the patient's room, while at the same time she shared with Employee #6 that Patient #1 was a snorer and she was not snoring and her hand was "Dark." She added that they entered the room and Employee #6 "...tilted her head towards the patient and indicated she heard breathing. At this time, she again shared her concerns to Employee #6 that she still doesn't hear her. Employee #6 told her that she is breathing "low."

Employee #5 was asked to describe what she observed about Patient #1 when she entered the room at approximately 3:15 AM and before she alerted Employee #6. She reiterated that she opened the patient's door and entered the room and called out her name twice and didn't get a response. She indicated that the patient was usually was snoring and wasn't snoring. She noticed the patient was lying "Face down" on her belly with her head "Slightly" turned towards the door. She mentioned, "You couldn't see her eyes through her hair, but you could see her hand and it looked discolored."

Next, Employee #5 explained her scheduled 1:1 time was from 5:00 AM till 7:00 AM or soon after. She indicated that at 5:00 AM she relieved Employee #3 and started her 1:1. She indicated at 5:00 AM or a short time after, she called out the patient's name and she did not answer. She indicated the patient's body was covered with her right hand exposed, so she pulled the cover back and noticed the discoloration was on her arm and her back, as well as on the hand she reported to Employee #6 at approximately 3:15 AM.

At that point, Employee #5 walked in and she proceeded to instruct Employee #3 to get Employee #8, because she could see him washing his hands from the patient's room. Employee #5 indicated Employee #8 entered the room and they proceeded to turn Patient #1 over. Employee #5 stated, "Her eyes were open, blood from her nose and saliva was covering her face." She added that both hands were up by her face discolored.

Employee #5 ended the interview by indicating the paramedics came first, then the fire department. She mentioned that she remembered one of the paramedics had made a statement that the patient had been gone awhile.

On 4/29/10 at 1:38 PM a telephonic interview was conducted with Employee #6. Employee #6 was interviewed to describe her duties during the night shift from 11:00 PM on 4/3/10, and till end of shift on 4/4/10. The employee indicated she was scheduled for the "A" unit. Employee #6 indicated she participated in unit report, did medication reconciliation and between 2:00 AM and 4:00 AM assisted in the dinner breaks for the technicians on "A" unit.

Employee #6 was asked if at any time during the early part of the shift she made any observations of the "B" unit. The employee indicated at approximately 3:00 AM she looked over to the "B" unit and observed no one in clear site. She indicated she observed no staff sitting at the bedroom door of Patient #1.

Employee #6 was asked what occurred at approximately 3:15 AM when Employee #5 asked for your assistance with Patient #1. Employee #6 indicated that she could not hear Patient #1 snoring any more. Employee #6 denied any other information was shared (discolored hand and no response to her name). Employee #6 added that she and Employee #5 entered the patient's room and Employee #6 stood over the patient and indicated she could hear breathing. Employee #6 denied any attempt to arouse the patient to observe a response.

Employee #6 was asked at any other time did she observe the "B" unit. She indicated at approximately 4:25 AM she inquired about the whereabouts of Employee #7. She indicated that she did not observe staff at the patient's door engaged in the 1:1. She could not remember the technician's name that had not seen Employee #7 since leaving on her scheduled 3:00 AM break.

Employee #6 was interviewed about the patient 's change of condition. She indicated that she left the unit to go on break at 5:10 AM and proceeded to her office. At approximately 5:20 AM she had responded to the code called on Patient #1. She indicated as she entered the room she observed Employee #7 attempting to obtain a pulse and was told she felt "...palpable wrist pulse..." Employee #6 added that Employee #7 was conducting chest compressions and she was using the Ambu bag, then she and Employee #7 switched due to each of their location at the patient ' s side.

Employee #6 further indicated that a nurse from another unit responded and she switched out with her so she could make additional calls. She indicated once the paramedics arrived, they hooked the patient up and indicated she was in a systole and stopped all life support. She indicated the AED was on the cart that Employee #8 rolled in during the code and was not utilized during the code procedures.

Employee #6 was asked if at the time she entered the patient's room during the code, could she describe the patient. She indicated the patient was on her back, arms over the head and she acknowledged the discoloration of the patient's arm and areas of the back. She also acknowledged that she looked rigid and not flaccid.