HospitalInspections.org

The facility failed to ensure the patients' care were provided in a safe environment, for nine of 21 sampled patients (Patients 3, 4, 6, 11, 13, 16, 17, 19, and 21), when:

1. For Patient 3, who was on a 5150 hold (an involuntary hold for 72 hours), was found in the bathroom unresponsive and unsupervised with a cord tied around his neck.

This failure resulted in Patient 3's eventual death (Refer to A-0144);

2. For Patient 6, assessments were not conducted while the patient was in restraints, in accordance with the facility's policy and procedure.

This failure had the potential to place the patient at an increased risk of serious injury (Refer to A-0179); and

3. Consents for the Conditions of Admissions were not completed for eight of 21 sampled patients (Patients 4, 6, 11, 13, 16, 17, 19, and 21).

These failures posed the increased risk for the patients to not be informed of their rights as the patients receiving care in the hospital (Refer to A-0116).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the patients' rights were protected.

Based on interview and record review, the hospital failed to ensure the consents for the Conditions of Admissions were completed, for eight out of 21 sampled patients (Patients 4, 6, 11, 13, 16, 17, 19, and 21), in accordance with the facility's policy and procedure. These failures posed the increased risk for the patients to not be informed of their rights as the patients receiving care in the hospital.

Findings:

On January 23, 2024, an unannounced visit was conducted at the facility for a complaint validation survey.

On January 24, 2024, at 10:40 a.m., a review of the medical records of Patients 4, 6, 11, 13, 16, 17, 19, and 21, was conducted with the Director of Patient Access Services (DPAS).

The records indicated the following:

- For Patient 4, the facility's document titled, "Face Sheet," dated January 2, 2024, indicated, "...Admitting Information, ADM [admit] DATE 01/02/2024 [January 2, 2024], TIME 0317 [3:17 a.m.]...ADM DIAGNOSIS ACUTE RESPIRATORY FAILURE [inefficient breathing]..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 2, 2024, indicated, "...MUATS [medically unable to sign]..."

- For Patient 6, the facility's document titled, "Face Sheet," dated January 15, 2024, was reviewed. The document indicated, "...Admitting Information, ADM [admit] DATE 01/15/2024 [January 15, 2024], TIME 0458 [4:58 a.m.]...ADM DIAGNOSIS SEVERE SEPSIS [a life-threatening infection in the blood]..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 15, 2024, indicated, "...pt [Patient 6] unable to sig [sic]..."

- For Patient 11, the facility's document titled, "Face Sheet," dated January 8, 2024, was reviewed. The document indicated, "...Admitting Information, ADM DATE 01/08/2024 [January 8, 2024], TIME 2356 [11:56 p.m.]...ADM DIAGNOSIS ALTERED SENSORIUM [confusion]..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 8, 2024, indicated, "...RELATIONSHIP IF NOT PATIENT SIGNATURE ... GARCSH [registration staff initials ]..."

- For Patient 13, the facility's document titled, "Face Sheet," dated January 20, 2024, was reviewed. The document indicated, "...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 2155 [9:55 p.m.]...ADM DIAGNOSIS CELLULITIS [infection of skin] OF ARM, LEFT..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 20, 2024, indicated, " ...PT [Patient 13] UATS [unable to sign] ..."

- For Patient 16, the facility's document titled, "Face Sheet," dated January 22, 2024, was reviewed. The document indicated, "...Admitting Information, ADM DATE 01/22/2024 [January 22, 2024], TIME 1529 [3:29 p.m.]...ADM DIAGNOSIS UTI [urinary tract infection]..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 20, 2024, indicated, "...VERBAL AUTH [authorization] REQUESTED-WEAKNESS..."

- For Patient 17, the facility's document titled, "Face Sheet," dated January 20, 2024, was reviewed. The document indicated, "...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 1119 [11:19 a.m.]...ADM DIAGNOSIS SEIZURE LIKE ACTIVITY..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 20, 2024, indicated, " ...PT [Patient 17] MEDICALLY UNABLE TO SIGN ..."

- For Patient 19, the facility's document titled, "Face Sheet," dated January 20, 2024, was reviewed. The document indicated for Patient 19, "...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 0041 [12:41 a.m.]...ADM DIAGNOSIS SOCIAL PROBLEM..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 19, 2024, indicated, " ...PT [Patient 19] UATS [unable to sign] ..."

- For Patient 21, the facility's document titled, "Face Sheet," dated January 12, 2024, was reviewed. The document indicated, "...Admitting Information, ADM DATE 01/12/2024 [January 12, 2024], TIME 0316 [3:16 a.m.]...ADM DIAGNOSIS ALTERED MENTAL STATE..."

The facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated January 11, 2024, indicated, "...no interview pt [Patient 21] unresponsive..."

There was no documented evidence the patient/authorized legal representatives' signed the form "Condition of Admission/Registration Treatment Authorization and Financial Responsibility." There was no documented evidence of the reason why the patients' or the patients' legal representatives' signatures were not obtained for Patients 4, 6, 11, 13, 16, 17, 19, and 21.

An interview and record review were conducted with the DPAS on January 24, 2024, at 10:48 a.m. The DPAS stated the Condition of Admission/Registration Treatment Authorization and Financial Responsibility forms for the above patients were incomplete and were filled out incorrectly per the facility's policy. The DPAS further stated if the patient is unable to sign, then a legally authorized representative will sign if available, and if that person is not available then two registration personnel will sign and date the form per the facility's policy.

A review of the policy and procedure (P&P) titled, "Consents," dated April 28, 2022, was conducted. The P&P indicated, "...Every competent adult person has the fundamental right of self-determination over his orher [sic] person and property. Individuals unable to exercise this right, such as minors and incompetent adults, have the right to be represented by another who will protect their interests and preserve their basic rights. The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment, unless emergency consent applies...Incompetent Adult Patients Not Under a Conservatorship...The patient's closest available relative/designated decision-maker has given consent. The Bioethics Committee may be convened to assist in identifying a decision-maker. This is an individual who has an understanding of the patient's current wishes and acts in the patient's best interest regardless of marital status or a familiar relationship...In the event that the patient cannot write a legible signature, the patient's mark must be obtained. The hospital representative should write the patient's name in full. The patient should place his X beneath his name. Two persons must witness the patient placing his mark on the form...Consent by Other Means The responsible physician or designee shall discuss the patient's condition and the recommended treatment with patient's legal representative for health care treatment. Telephone Consent..."

Based on observation, interview, and record review, the facility failed to ensure a safe environment was provided for one patient (Patient 3), when Patient 3, who was on a 5150 hold (an involuntary hold for 72 hours), was found in the bathroom unresponsive and unsupervised with a cord tied around his neck.

This failure resulted in Patient 3's eventual death.

Findings:

A tour of the Intensive Care Unit (ICU, unit for critically ill patients) was conducted on January 23, 2024, at 9:54 a.m., with the Chief Nurse Officer (CNO) and ICU Manager (ICUM).

During an observation on January 23, 2024, at 10:26 a.m., in Patient 3's room, Patient 3 was observed to be unresponsive when Sitter1 called Patient 3's name and when she tried to stimulate him to wake up. A very faint ligature mark was observed on Patient 3's neck.

During an interview on January 23, 2024, at 10:34 am, conducted with Patient 3's family member (FM 1), FM 1 stated he came the next day and informed the staff that he believed the motor vehicle accident was not an accident but a suicide attempt. FM 1 stated Patient 3's behavior changed after a loss of a family member two years ago to cancer. The FM stated they noticed Patient 3 was more depressed and had sought help for it multiple times.

On January 24, 2024, at 10:30 a.m., a review of Patient 3's record was conducted with Emergency Department Manager (EDM).

A review of the facility document titled, "History and Physical," dated January 7, 2024, indicated Patient 3 was admitted on January 7, 2024, with a diagnosis of encephalopathy (a brain disease that alters brain function or structure).

A review of an undated facility document titled, "Diagnoses," indicated, "...Diagnosis: Depression with Anxiety ...Diagnosis date: 01/08/2024 [January 8, 2024]..."

A review of Patient 3's physician's order, dated January 8, 2024, written at 4:59 p.m., indicated, "...Suicide Precaution ...Now..."

A review of Patient 3's physician's order, dated January 8, 2024, written at 7:07 p.m., indicated, "...Ongoing Suicide Assessment...routine BID [two times a day]...order comment: placed by dicern expert [software program] based on documentation of Suicide Risk [Name of tool] Assessment..."

A review of facility document titled, "Physician Progress Note," dated January 10, 2024, indicated, " ...Assessment/Plan...Bipolar, acute mixed episode with psychotic features...reconsulted psychiatry...given patient has continued experience paranoia and has tried to escape hospital..."

A review of facility document titled, "Psychiatry Consult Notes," dated January 10, 2024, indicated, "...Chief Complaint: "I just had an urge to run." Reason for Consultation: determine psychiatric disposition, patient is medically cleared. Subjective...Staff report patient continues to show paranoia with impulsive behaviors. Code Grey called last evening as patient suddenly bolted out of the room. He made it to the emergency room lobby...Transfer, discharge, and level of care: Patient's psychiatric condition has not continued to improve. Although he retains good insight, his mania and psychosis is progressing and he meets 5150 hold criteria for grave disability and danger to self..."

A review of facility's document titled, " History and Physical," dated January 11, 2024, indicated, "...7:10 pm 1/11 [January 11, 2024] code blue [unexpected cardiac or respiratory arrest requiring resuscitation] called pt [patient] found attempting to hang self in bathroom with call light cord around his neck. Pt [patient] went into PEA [Pulseless Electrical Activity, a type of irregular heart rhythm] arrest...received CPR [Cardiopulmonary Resuscitation, procedures to attempt to resuscitate] for 5 [five]-10 [ten] min [minutes]...He was intubated [insertion of a tube in the airway to assist in breathing] successfully during CPR...pt [Patient 3] moved to ICU..."

A review of the transportation service untitled document, dated January 11, 2024, indicated, "...Crew obtained a report on pt [patient] before entering the pt [patient] room around 1857h [6:57 p.m.]. EMT [Emergency Medical Technician, Name of ambulance staff] was obtaining the last bit of the report and signature from RN [registered nurse] when EMT [Name of ambulance staff] walked into the pt [patient] room. EMT [Name of ambulance staff] found two family members at the bedside. They told her the pt [patient] was using the restroom since it was a long drive...the family notified him [RN] that the patient was in the restroom. RN knocked but no answer came...RN opened the door and when EMT [Name of ambulance staff] saw the pts [patient's] legs she ordered the family to leave immediately...The RN pulled the pt out from the toilet and the wall...and called a code blue..."

A review of facility record titled, "Cardiopulmonary Resuscitation Record," dated January 11, 2024, indicated, " ...Event recognized date: 01/11/2024 [January 11, 2024], Time: 1907 [7:07 p.m.]... witnessed arrest...1908h [7:08 p.m.] breathing assisted...no BP (blood pressure)...Rhythm...PEA...1921h [7:21 p.m.] Reason Resuscitation ended- Survived...1923 [7:23 p.m.] transferred to ICU..."

A review of facility document titled, "Discharge Summary," dated January 25, 2024, indicated Patient was unresponsive overnight and time of death was declared at 1:30 a.m. on January 25, 2024.

There was no documented evidence the "Environmental Rounds to Secure Rooms (Including Bathrooms) for Suicidal Patients form" was completed on January 10, 2024.

There was no documented evidence a suicide risk assessment was conducted for Patient 3 from January 9, 2024, through January 18, 2024.

During an interview on January 24, 2024, at 1:36 p.m., conducted with RN 1, RN1 stated he did not document a suicide risk assessment even after he was informed of Patient 3's 5150 hold. RN 1 stated he did not know who was watching Patient 3 during the time he was giving report to Transportation Staff 1. RN 1 further stated he allowed the sitter to leave the room because he assumed Transport Staff 2, who was in the room, was watching Patient 3.

During a concurrent interview and record review on January 24, 2024, at 1:42 p.m, conducted with RN 1, the "Environmental Rounds to Secure Rooms (Including Bathrooms) for Suicidal Patients form," dated January 11, 2024, completed by Sitter 3 at 6 a.m., was reviewed. The document indicated, "...Things to be checked...Room is free from hanging or strangulation hazard...call bell cord...Yes box marked..." RN 1 stated the bathroom cord used by Patient 3 on his suicide attempt was not removed because RN 1 did not know how to remove it.

During an interview on January 25, 2024, at 9:57 a.m., conducted with FM 2, FM 2 stated when RN 1 was giving report and the sitter left the room, Patient 3 got out of bed and went to the bathroom. FM 2 stated no staff were watching or supervising Patient 3 while he was in the bathroom. FM 2 further stated she notified RN 1 when she noticed Patient 3 was in the bathroom for too long.

During an interview on January 25, 2024, at 11:01 p.m., conducted with House Supervisor (HS), the HS stated she was notified by the case manager that a 5150 evaluation was needed for Patient 3. The HS stated, after her evaluation of Patient 3, she deemed Patient 3 as a danger to self and issued the 5150 hold.

During an interview on January 25, 2024, at 1 p.m., conducted with Sitter 2, Sitter 2 stated she was not assigned as a sitter for Patient 3, however, she volunteered to sit with Patient 3 until he was discharged. Sitter 2 stated she left the room for a few minutes and when she returned Patient 3 was in the bathroom. She further stated she was not watching Patient 3 while he was in the bathroom nor was she aware that he was on a 5150 hold.

During an interview on January 25, 2024, at 3 p.m., conducted with Sitter 3, Sitter 3 stated she left when the incident happened, however, she mentioned to RN 1 that Patient 3 was going to the bathroom more frequently than normal that day.

A review of the policy and procedure (P&P) titled, "Identification and Management of Patients At Risk for Suicide," dated April 14, 2023, indicated, "...Purpose: The purpose of this policy is to outline the requirements for ensuring the safety of patients with actual or potential thoughts of self-harm or suicide...It is the policy of [Name of facility] to identify and assess patient at risk for suicide. Suicide Risk screening will be conducted on all patients entering the facility...Procedure...Screening and Assessment for Suicidal Ideation...Depression, hopelessness, or sadness during the past month...Patient environment....Prior to placing a patient in any non-designated area who is assessed as at risk for suicide, staff shall conduct and document a safety risk assessment of the patient environment and identify features and objects that could be used by the patient for self-harm...Observation...For patient assessed as moderate or high risk for suicide, maintain continuous observation during patient's use of bathroom..."

Based on interview and record review, the hospital failed to ensure assessments were conducted on a patient on restraints, for one of 21 sampled patients (Patient 6), in accordance with the facility's policy and procedure.

This failure had the potential to place the patient at an increased risk of serious injury.

Findings:

A review of Patient 16's record was conducted on January 25, 2024. The "History and Physical," dated January 22, 2024, indicated Patient 16 was admitted to the facility on January 22, 2024, with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities).

The document titled, "Physician Orders for Restraint Use," indicated soft wrist restraints was ordered for Patient 16 on January 22, 2024, at 12:29 p.m., through January 23, 2024, at 5:42 p.m.

There was no documented evidence the patient's restraint use was assessed every four hours on January 23, 2024, between 4:01 a.m. and 5:59 p.m.

An interview and record review was conducted with Unit Manager (UM) 1 on January 25, 2024, at 9:20 a.m. UM 1 stated there was no documentation which indicated Patient 16 was assessed every four hours on January 23, 2024. UM 1 stated the facility's policy and procedure was not followed. She further stated the registered nurse should have documented Patient 16's restraints at 8:00 a.m., 12 p.m., and at 4:00 p.m., on January 23, 2024.

A review of the facility's policy and procedure titled, "Restraints," indicated, "...To provide guidance for the use and management of restraints...The assessment is documented in the patient's record...Documentation of monitoring is expected to occur a minimum of every 4 [four] hours...Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms and computer screens and may include skin integrity, hygiene, nutrition, elimination, circulation, vital signs, and reaction to restraints..."

Based on interview and record review, the hospital failed to ensure assessments were conducted on a patient on restraints, for one of 21 sampled patients (Patient 6), in accordance with the facility's policy and procedure.

This failure placed the patient at an increased risk of serious injury.

Findings:

A review of Patient 16's record was conducted on January 25, 2024. The "History and Physical," dated January 22, 2024, indicated Patient 16 was admitted to the facility on January 22, 2024, with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities).

The document titled, "Physician Orders for Restraint Use," indicated soft wrist restraint was ordered for Patient 16 on January 22, 2024, at 12:29 p.m., through January 23, 2024, at 5:42 p.m.

There was no documented evidence the patient's restraint use was assessed every four hours on January 23, 2024, between 4:01 a.m. and 17:59 p.m.

An interview and record review was conducted with Unit Manager (UM) 1 on January 25, 2024, at 9:20 a.m. UM 1 stated there was no documentation which indicated Patient 16 was assessed every four hours on January 23, 2024. UM 1 stated the facility's policy and procedure was not followed. She further stated the registered nurse should have documented Patient 16's restraints at 8 a.m., 12 p.m., and at 4 p.m., on January 23, 2024.

A review of the facility's policy and procedure titled, "Restraints," indicated, "...To provide guidance for the use and management of restraints...The assessment is documented in the patient's record...Documentation of monitoring is expected to occur a minimum of every 4 [four] hours...Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms and computer screens and may include skin integrity, hygiene, nutrition, elimination, circulation, vital signs, and reaction to restraints..."