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Based on policy and procedure review, medical record review, facility documents, and staff interviews, the facility failed to follow its' grievance management policy. (Patient #2)

The findings include:

Review of the facility's policy titled "Patient Grievance Management Process" (Next Review/Revision date: June, 2019) "POLICY: ...seeks to provide prompt review and timely resolution of complaints and grievances ...Response to a Grievance ...4. Within seven calendar days, the patient or legal representative will be contacted by the Office of Patient Experience to address resolution or notify the patient or representative that further investigation is required. The patient will be informed of an expected follow-up time to address the resolution and will be kept informed of the process on a weekly basis ...7. At the conclusion of the grievance review, the Office of Patient Experience will send written correspondence to the patient or legal representative including (Named Facility) contact person, title, phone number, steps taken in the investigation, finding, and date investigation was completed ..."

Medical record review on 07/19/2017 revealed Patient #2 was a 68 year old female who arrived in the emergency department (ED) on 07/06/2016 at 1441 after a fall at home while attempting to sit on a swivel chair. The patient transported by emergency medical services to a local hospital emergency department, and was admitted to an inpatient stepdown room after undergoing initial evaluation and testing. Review of a Critical Care service telemedicine medical doctor (MD #5) note dated 07/07/2016 at 2143 revealed "68 yo (year old) female admitted for fall, hyperglycemia, HTN urgency, found the floor (sic) with vomitus over her body (sic), unresponsive, no pulse, CODE BLUE initiated. ACLS (Acute Cardiac Life Support) performed for roughly 25 mins (minutes), PEA (Pulseless Electrical Activity-electrical activity of the heart without contraction of the heart muscles) and Vfib\vtach (Ventricular fibrillation\Ventricular tachycardia-dysfunctional contractions of the main pumping chambers of the heart) noted, shock x 2 then ROSC (Return of Systemic Circulation)." The note included plans for additional testing to be done. Additional record review of a "Progress Note" by a Critical Care Service Nurse Practitioner ( NP #1) on 07/06/2016 at 2225 revealed he "...Was called by (MD # 5) to evaluate patient during cardiac arrest. Patient had one episode of PEA arrest for 25 min (minutes) prior to my arrival. This was reportedly incited by an aspiration event with rapid desaturation, and eventual loss of pulses. ROSC was achieved, however upon my arrival she was again in cardiac arrest ...2nd code in all lasted about an additional 25 mins ..." Medical record review revealed that MD #5 pronounced the Patient #2 dead on 07/07/2016 at 2219.

Facility documents review on 07/19/2017 revealed that a grievance by Patient #2's family was logged on 07/22/2016, and because a "Risk Management Specialist", had talked with Patient #2's daughter, "Risk Management" would serve as "...primary contact for this family." Facility internal communications review revealed summaries of staff conversations with Patient #2's daughter which occurred on 07/10/2016, 07/11/2016, 07/19/2016, 07/20/2016, and 08/05/2016. Review of facility documents revealed a condolence letter from the "Office of Patient Experience" was sent to Patient #2's daughter on 08/22/2016. The letter contained an "Office of Patient Experience" staff member's name and title, as well as the contact number for the Risk Management Team." Documents review revealed that the event review had been closed on 08/22/2016. A request to administrative staff member (AS #1) on 07/20/2017 for additional correspondence from the facility to the family yielded no additional materials. Review confirmed the grievance acknowledgement/condolence letter was sent on 08/22/17 (30 days after the grievance was received).

Interview with administrative staff member (AS #1) on 07/19/2017 at 1405 revealed that a timeline review of Patient #2's inpatient stay for the period which began on 07/06/2016 had been done. An initial response to Patient #2's daughter's complaint which had been registered in the hospital system on 07/25/2016 had been sent by the Office of Patient Experience on August 22, 2016. Interview revealed there was no available documentation to indicate weekly communication with the family regarding progress of the grievance review. Interview with AS #1 confirmed the finding.

Based on policy and procedure review, medical record review, and staff interviews, the facility failed to ensure changes in medical condition was effectively communicated between care staff, providers, and family. (Patient #2).

The findings include:

Review of the facility's policy on 07/18/2017 titled, "Nursing Process, and Physical Assessment Standards" (Effective Date: September 4, 2012) "The purpose ...is to define the standards for the Nursing Process that guides the care provided to the patient ...Assessment ...on admission ...as well as ongoing assessments ...throughout the patient's stay."

Review of the facility's policy on 07/18/2017 titled, "Deceased Patient Management" (Next Review/Revision date: June 2019) " ...Physician ...4. Ensures notification of family or next of kin when death occurs ...Registered Nurse 1. Has the professional responsibility as a patient advocate and is held accountable for providing/maintaining a safe and effective nursing care (sic) and accepting responsibility for individual nursing actions, competence and behavior ...6. Notifies the physician of the death and conveys any family request(s) ..."

Medical record review on 07/19/2017 revealed Patient #2 was a 68 year old female who arrived in the emergency department (ED) on 07/06/2016 at 1441 after a fall at home while attempting to sit on a swivel chair. The patient was transported by emergency medical services to a local hospital emergency department, and was admitted to an inpatient stepdown room after undergoing initial evaluation and testing. Review of a telemedicine Critical Care medical doctor (MD #5) note dated 07/07/2016 at 2143 revealed "68 yo (year old) female admitted for fall, hyperglycemia, HTN urgency, found the floor (sic) with vomitus over her body (sic), unresponsive, no pulse, CODE BLUE initiated. ACLS (Acute Cardiac Life Support) performed for roughly 25 mins (minutes), PEA (Pulseless Electrical Activity-electrical activity of the heart without contraction of the heart muscles) and Vfib\vtach (Ventricular fibrillation\Ventricular tachycardia-dysfunctional contractions of the main pumping chambers of the heart) noted, shock x 2 then ROSC (Return of Systemic Circulation)." The note included plans for additional testing to be done. Additional record review of a "Progress Note" by Critical Care service nurse practitioner staff, NP #1, on 07/06/2016 at 2225 revealed he "...Was called by (MD #5) to evaluate patient during cardiac arrest. Patient had one episode of PEA arrest for 25 min (minutes) prior to my arrival. This was reportedly incited by an aspiration event with rapid desaturation, and eventual loss of pulses. ROSC (Return of Spontaneous Circulation) was achieved, however upon my arrival she was again in cardiac arrest ...2nd code in all lasted about an additional 25 mins..." Medical record review revealed that MD #5 pronounced Patient #2 dead on 07/07/2016 at 2219. Review revealed no documentation that the admitting, Hospitalist Service, medical team was notified of the Patient #2's change in condition, or death.

Interview with administrative staff member (AS #1), on 07/19/2017 at 1410 revealed that a timeline review of the named patient's care had been conducted. Interview revealed transfer of care from the Hospitalist Service to the Critical Care Service had been assumed by staff involved in the resuscitation events. Patient #2's death had not been communicated to the Hospitalist Service until two days after the event; when a death follow up was requested of MD # 3 who had been assigned the named patient's care on the morning of 07/07/2016. Interview with AS #1 confirmed the finding.

Interview with MD # 3 on 07/20/2017 at 0950 revealed she had seen the named patient on 07/07/2016, and it was her impression that Patient #2 was more alert than her admission note indicated, her blood pressure was stable, and she was " ...doing well when I left." Interview revealed that the physicians in the Hospitalist group work daily from 0700 to 1900, and coverage from 1900 to 0700 the next morning was provided by nurse practitioner and physician assistant staff members of the group. Interview revealed that the Hospitalists MD's typically saw fifteen to eighteen patients daily, the Patient #2 was not on MD #3's assignment list on 07/08/2016, and neither she or her service had been informed of the Patient #2's death on 07/07/2016. Interview revealed MD #3 learned of the death two days later when she received a hospital system request for a death follow up, and " ...was surprised no one notified me." Interview with MD #3 confirmed the finding.

Based on policy and procedure review, closed medical record review, internal incident report review, the facility's video monitoring of the Resident treatment area, and staff interviews, the facility staff failed to ensure staff were competent in preventing 1 of 1 patient on restrictive precautions from leaving the locked unit (Patient #25).

The findings include:

Review on 07/20?2017 of the policy and procedure titled "Care of the Homicidal and Suicidal Patient" last reviewed 12/2014 revealed "PURPOSE:...The purpose of the policy is to establish procedures, which support the following:...Appropriate protection and treatment for patients or others at risk...POLICY:...Patients demonstrating ideation, impulses, or behavior indicating that they are a danger to themselves or others should be managed in such a way as to minimize the threat of injury or harm.... PROCEDURE:...Restrictions include:...The patient should be restricted to a secure, locked unit, unless otherwise noted by a physician...."

Closed medical record review on 07/19/2017 of the "Encounter Notes" by the NP #1 (Nurse Practitioner) dated 06/20/2017 at 1402 revealed Patient #25, a 29 year-old male was admitted to the hospital on 06/19//2017 with the diagnosis of "MDD (major depressive disorder), recurrent severe without psychosis...Schizoaffective disorder, depressive type..." Review revealed the patient presented with signs and symptoms "of depression and suicidal ideation with thoughts of cutting himself with a knife...." Further review revealed the patient was at risk to himself but was not at risk to others. The patient was admitted to the inpatient adult co-ed behavioral health open (not locked) 400 hall room 407 with a treatment plan for crisis management and mood stabilization. Review of the "Encounter Notes" by NP #1 dated 06/21/2017 at 1349 revealed the patient's "Psychiatric Specialty Exam" presentation consisted of anxiety and depression but was negative for suicidal or homicidal ideas and hallucinations. The treatment plan included "...Individual and group therapy..." Review of "Care order/instruction..." by NP #1 dated 06/22/2017 at 1019 revealed "Comments...Pt restricted to the unit for 24 hours for inappropriately touching another pt, being sexually inappropriate and wandering into another pt room." Review revealed Patient #25 was transferred from the 400 hall to the inpatient adult behavioral health locked (secured via locked doors) unit 500 hall on 06/22/2017 at 1049. Review of the "Precautions Record" fifteen minute safety checks list by MHT (Mental Health Technician) #1 dated 06/22/2017 for the following times 2015, 2030,2 045, 2100, 2115 and 2130 indicated Patient #25 attended a group activity (karaoke) in the cafeteria. Review revealed Patient #25 was not restricted to the locked unit as ordered for the twenty-four hour timeframe.

Closed medical record review on 07/18/2017 of the "H&P" (History and Physical) by MD #1 (Medical Doctor Psychiatrist) dated 06/22/2017 at 1037 revealed Patient #22 was a 29 year old female admitted on 06/21/2017 with the diagnosis of "MDD (major depressive disorder) recurrent severe, without psychosis" Review revealed "...Patient voluntary...Sts (States) she is not suicidal....Today patient sts that she is increasing depressed....Patient's depression is triggered by her lack of psychiatric medication regimens not working. Sts that she has been taken off medications and restarted on new medications over the past several months....Patient is agitated because she feels that a male patient had been in her room last night and she was touched. Patient agitated...." Review revealed Patient #22 was admitted to the inpatient adult co-ed behavioral health open (not locked) unit 400 hall, room 406. Review of "Progress Notes" by RN (Registered Nurse) #2 dated 06/22/2017 at 2145 revealed "...Pt informed the writer that one of her peers, whom had been informed ...that (Patient #25) was to stay on the unit for at least 24 hrs, had gone to karaoke. Writer apologized to the pt and informed she was unaware of the order. Pt informed the writer that her peer didn't attempt to speak to her, however states she 'didn't feel safe'...." Review of Progress Notes by MHT #2 dated 06/22/2017 at 2130 revealed "...Pt came to this writer at 2120, the end of karaoke group and mentioned that another patient was in the cafeteria that she said was supposed to remain on the unit for 24 hours. Pt reported this made her feel uncomfortable...." Review of the "Precautions Record" fifteen minute safety checks list by MHT (Mental Health Technician) #3 dated 06/22/2017 for the following times 2015, 2030, 2045, 2100, 2115 and 2130 indicated Patient #22 attended group activity. Further review revealed no evidence of the group activity location.

Review on 07/19/2017 of the internal incident report revealed the incident occurred on 06/22/2017 at 0600 and was reported to RN #1 on 06/22/2017 at 1000. Review revealed the "...Patient reported that a male patient was in her room this morning. Patient reported that the male patient was touching her hair and pulled her bed cover back off of her. Patient can't remember how her underwear was pulled down when she got up this morning. The male patient admitted going into patient room to wake her up....Patient is angry, irritable and agitated...." Review revealed MD #1 was notified of the incident on 06/22/2017 at 1000. Further review revealed "Physician Action:...Patient educated (Patient #25), transferred to another unit and restricted to unit x 24 hours."

Review on 07/19/2017 at 1213 of the facility's video monitoring of the Resident treatment area dated 06/21/2017 at 2309 through 06/22/2017 at 0840 revealed, Patient #25 entered Patient #22's room on 06/22/2017 at 0642:41 and exited the room at 0643:27.

Interview on 07/20/2017 at 1139 with AS #1 revealed there is not a specific policy for restrictions, but, the restrictions noted in the homicidal and suicidal policy included all the behavioral health patients. AS #1 revealed the restrictions for each patient were documented in the restriction orders.

Interview on 07/20/2017 at 1145 with AS #2 revealed re-education was done after the incident but most of the re-education will be done during staff meetings on 07/27/2017 and 07/30/2017.

Interview on 07/20/2017 at 1015 with MHT #1 revealed she worked on the 500 hall (locked unit) on 06/22/2017 from 1900 through 0700 06/23/2017. Interview revealed Patient #25 did attend the karaoke session on 06/22/2017. Interview revealed during huddle at 1900 on 06/22/2017 the only information relayed about Patient #25 was that he had been transferred from the 400 hall to the 500 hall. Interview revealed patients restricted to the hall were not allowed off the hallway except for meals. MHT #1 stated "...I asked a nurse, I do not remember the nurse and she was questioning the same thing and we thought it was ok for group because that is why they are here....group music therapy....I felt group was different." Interview revealed she did not receive re-education related to the restriction policy and procedure. MHT #1 stated " I would be notified during huddle if working directly with the patient." Interview revealed she would be notified by "the nurse or other MHT, everyone has ways of knowing patients are on restriction whether they are working directly with them or not."

Interview on 07/20/2017 at 1042 with RN #2 revealed she worked on the 500 hall (locked unit) on 06/22/2017 from 1900 through 0700 06/23/2017 and Patient #25 was her patient during the shift. Interview revealed Patient #22 from the 400 hall reported to RN #2 she was told Patient #25 was not to have any contact with her (Patient #22). RN #2 apologized to Patient #22 and explained she "...was not aware he was not suppose to go off the unit and it would not happen again..." Interview revealed RN #2 was not informed of the restriction order for Patient #25 during the 1900 shift change report. Further interview revealed RN #2 "...did not have a chance to read all of the chart" for Patient #25. Interview revealed RN #2 received "report from various people" that Patient #25 went into a female's room. RN #2 revealed restriction means patients "can not go off their hall". Interview revealed RN #2 "read a little more in his (Pateinet #25) chart. Read the order, something ... saying he was not suppose to go off the hall." RN#2 revealed she had the freedom to hold a patient on the hall even if the patient was suspected to be inappropriate with other patients. Interview revealed RN #2 did not receive re-education after the incident and stated she "has to be more vigilant on the hall and pay more attention so this does not happen again."

Based on the hospital's policies and procedures, observation and staff interview, the hospital's nursing staff failed to
prepare and administer intravenous (IV) injectable medications to a patient in a clean medication preparation area for one of three observed patients administered IV medications from the hospital's nursing staff (Registered Nurse (RN) #2, Patient #18).

The findings include:

Review on 07/19/2017 of the hospital's policy "Medication Distribution, General Practices" (Revised 04/25/2016), revealed "Delivery and patient care personnel will be responsible for ensuring that medications are placed in the appropriate safe and secure storage location (i.e, medication bins or refrigerators) on the patient care units immediately upon receipt of the medication from the pharmacy. All drugs removed from a medication storage area (e.g., medication cart, UBC [Not defined]) must be removed just prior to administration and only for one patient at a time. The drug should not be left on or in any area exceeding 80 degrees Fahrenheit, including pockets."

1. Observation on 07/19/2017 at 1145 at the hospital's Campus #2 Emergency Department (ED) revealed RN #2 preparing and administering an IV injectable medication to patient #18. The observation revealed the RN entered the patient's room and removed a vial of medication "Zofran" (Anti-Nausea) medication and other IV supplies including a syringe from her lab coat pockets. The RN was then observed to insert an IV catheter into the patient's right arm area and remove blood into a syringe and then blood collection container directly from the IV line for a blood sample. Continued observation revealed the RN placed the blood collection container filled with blood down on the bedside table located with the vial of "Zofran" and syringe. The RN was observed to prepare the IV "Zofran" by opening the medication vial, wiping it with an alcohol pad and then inserting the syringe in order to remove the medication from the vial into the syringe. The observation then revealed the RN wiped the patient's IV access port with another alcohol pad and and administered the IV injectable "Zofran" into the patient's IV access port. The observation revealed the RN prepared and administered the IV injectable "Zofran" medication from a non-clean medication preparation area.

Interview on 07/19/2017 at 1156 with the Campus #2's ED Director revealed that the staff may carry some medications in their pockets if they only take them directly from the medication storage area directly to the patient. The interview revealed that medications in kept in the pockets should not be done routinely in the staff's practice. The interview also revealed she did not know how long RN #2 had the medications and supplies in her pockets.

Interview on 07/19/2017 at 1550 with with the hospital's Infection Preventionist #1 and Manager of Infection Prevention revealed that IV medications should be drawn up in clean areas. The interview also revealed that no concerns have been found in the past related to staff carrying medications and supplies in their pockets other than in anesthesia. The interview confirmed the observation finding that IV medications should be prepared and administered without potential cross-contamination.

Based on review of hospital policies and procedures, medical records, and clinical staff interviews, the facility failed to ensure documentation of vital sign response to intravenous medication titration was properly filed and retained. (Patient #2)

The findings include:

Review of the policy entitled "Continuous Infusion Medication Titrating Orders (Adult and Pediatric)" (Next Review/Revision date: August 2018) on 07/18/2017 revealed "POLICY: ...These orders provide the nurse an opportunity to adjust the dose up or down based on the patient's needs and provider-defined endpoints ...PROCEDURE: ...Documentation of monitoring parameters should reflect the patient's response to initiation of medication and subsequent titration."

Review of the policy entitled "Nursing Process, and Physical Assessment Standards" (Effective Date: September 4, 2012) on 07/18/2017 revealed "The purpose ...is to define the standards for the Nursing Process that guides the care provided to the patient ...Assessment ...on admission ...as well as ongoing assessments ...throughout the patient's stay."

Medical record review on 07/19/2017 revealed Ptient #2 was a 68 year old female who arrived in the emergency department (ED) on 07/06/2016 at 1441 after a fall at home while attempting to sit on a swivel chair. The patient was transported by emergency medical services to a local hospital emergency department, and was admitted to an inpatient stepdown room after undergoing initial evaluation and testing. Medical record review revealed her admitting Assessment/Plan included initiation of a continuous nitroglycerin infusion for blood pressure control, use of intravenous furosemide (a diuretic) to treat "volume overload ...and pulm(onary) vascular congestion," and admission to "stepdown." Review of the medical record revealed an order entered on 07/06/2017 at 1900 for nitroglycerin ...infusion ...Ordered dose: 0-200 mcg/min ...Titrated ...GOAL: SBP (systolic blood pressure) 140-150. INITIATE AT: 5 mcg/min. TITRATE BY: 5mcg/min to dose range maximum. INTERVAL: Every 3 minutes. Record review revealed the medication was begun on 07/06/2016 at 5 mcg/min when the named patient's SBP was 200. Medical record review revealed the medication was increased over the course of the evening and night from 07/06/2017 to 07/07/2017, and was infusing at 105 mcg/min on 07/07/2016 at 0610 when vital signs were recorded and the patient's SBP was 175. Review revealed the next vital signs were recorded on 07/07/2016 at 0620 with no change in dose indicated. No additional vital signs including SBP readings were available after 0620 until 1900 on 07/07/2016. Review revealed that the dose of nitroglycerin had continued to be increased until the maximum dose (200 mcg/min) was reached, initially, on 07/07/2016 at 1359. Review revealed the nitroglycerin was decreased to 195 mcg/min at 1415, increased again to 200 mcg/min at 1628 where it remained except for a decrease to 195 mcg/min on 07/07/2016 between 2010 and 2020. Medical review revealed vital signs and medication flow rates were again recorded every ten minutes beginning on 07/07/2016 at 1900 continued through 2110. Review of a Critical Care service telemedicine provider, MD #5, note dated 07/07/2016 at 2143 revealed "68 yo (year old) female ...CODE BLUE initiated. ACLS (Acute Cardiac Life Support) performed for roughly 25 mins (minutes), PEA (Pulseless Electrical Activity-electrical activity of the heart without contraction of the heart muscles) and Vfib\vtach (Ventricular fibrillation\Ventricular tachycardia-dysfunctional contractions of the main pumping chambers of the heart) noted, shock x 2 then ROSC (Return of Systemic Circulation)." The note included plans for additional testing to be done. Medical record review revealed a second note by the MD #5 on 07/07/2016 at 2229 that a second "CODE BLUE" had occurred and Pt #2 had been pronounced dead on 07/07/2016 at 2219. Review revealed no vital sign documentation associated with nitroglycerin titration was evident between 0610 and 1900 on 07/07/2016 for Patient #2.

Interview on 07/19/2017 at 1210 with Registered Nurse (RN) #3 who cared for the named patient from 0700 until 1900 on 07/07/2016 revealed the nurse typically worked on another floor in the facility, but was "floated" that day. Interview revealed she had cared for the named patient from 0700 to 1900 on 07/06/2016. Interview revealed the named patient's blood pressure had become more difficult to control within the treatment parameters around noon on 07/07/2016, and the nurse had paged a physician for new blood pressure medication orders since the nitroglycerin infusion was at the maximum dose. Interview revealed the nurse remembered recording vital signs in the electronic medical record, but was unaware, at the time, that the vital signs on the floor to which she had been "floated," required an additional verification step in order to be retained within the hospital record system. Interview confirmed the finding.

Interview with an administrative staff member, AS #1, on 07/19/2017 at 1405 revealed that there was no documentation that RN #3 who floated to the care unit on 07/07/2016 had been provided the usual orientation to the unit's processes and routines. Interview revealed that the missing vital signs could have been retrieved up to seventy-two hours after the documentation time if properly confirmed by staff, but "had not for some reason." Interview with AS #1 confirmed the finding.

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