HospitalInspections.org

Based on facility document review, policy review, video recording review, medical record reviews, observations and interview, the Governing Body failed to be effective in carrying out its responsibilities for the conduct of the hospital and ensure the hospital's ongoing compliance with all Conditions of Participation in order for quality of care to be provided to all patients. The failure of the Governing Body to carry out its responsibility for the oversight of the conduct of the hospital and failure to ensure all hospital policies and procedures to protect the safety and health of patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The Governing Body's failure to manage the hospital functions, improve processes to ensure quality of care and ensure an environment of safety resulted in 4 of 9 (Patient #1, #3, #6 and #7) sampled patients not receiving protective and safe care from the behavioral health hospital.

The findings included:

1. Review of the hospital's policy, "Patient Abuse or Neglect", last revised 8/2024, revealed the facility "will afford to patients the highest standards of clinical practice and human dignity. Staff members will demonstrate kindness...regardless of the patient's behavior...Inappropriate staff conduct may include, but is not limited to: Any physical violence which may result in injury such as...rough handling...Not performing duties safely..."

Review of the hospital's policy, "Patient Observation Guidelines," last revised 07/2024, revealed "It is the policy of [Facility #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient's behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked..."

Review of the hospital's policy "Vital Signs" last revised 11/2023 revealed, "...All patients...will have vital signs taken...as...warranted by patient's condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider..."

Review of the hospital's policy, "CPR [(Cardiopulmonary Resuscitation) - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]", last revised 12/2023, revealed "...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression..."

2. Review of the "Patient Admission Information" form dated 8/13/2024, revealed Hospital #1 is "... dedicated to providing a safe environment for its patients and staff..."

3. Review of the "Job Descriptions" for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to "...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you..."

4. The Governing Body failed to ensure patients' rights to receive care in a safe setting were followed for Patients #1, #3, #6 and #7.

Patient #1 was found unresponsive in the dayroom. There was no documentation the physician and/or nurse had been notified of the patient's decrease in blood pressure and oxygen saturation levels (normal is 90-100% of oxygen in the bloodstream) the four days prior to the patient being found unresponsive.

Patient #3 demonstrated aggressive behavior and was taken to seclusion. Observations of the hospital's video recording revealed Patient #3 was pushed into the seclusion room by the staff.

Patient #6 experienced low oxygen saturation for 2 days. There was no documentation of reassessments by the nurse nor physician/nurse practitioner notification of the patient's low blood pressure and oxygen saturations.

Patient #7 experienced low blood pressure and low oxygen saturations for 30 days. There was no documentation of reassessments by the nurse nor physician/nurse practitioner notification of the low oxygen saturations until she developed wheezing. Patient #7 was transferred to a local hospital where the Patient was admitted with Pneumonia.
Refer to A 115 and A 144.

5. The Governing Body failed to ensure Nursing Services adhered to facility policies to protect vulnerable Patients #1, #3, #6 and #7 from actual and/or potential harm. Nursing staff failed to perform assessments and reassessments of patients who were experiencing a decline in their vital signs and failed to notify the patients' physician and/or nurse of the patients' decline in vital signs. Patient #1 was found unresponsive and required CPR after experiencing 4 days of a decline in their vital signs without physician and/or nurse notification of the decline in the vital signs. Patient #7 experienced a decline in their vital signs for 30 days without physician and/or nurse notification and was transferred to the hospital with pneumonia. Patient #6 experienced a decline in their oxygen saturation and there was no physician notification. Nursing failed to protect all patients from all forms of abuse when staff were observed pushing on Patient #3 in order to get the Patient to go into the Seclusion Room.

Refer to A-115, A-144, A-385 and A-395.

Based on facility policy review, document review, medical record review, video recording review and interviews, the facility failed to ensure patients' rights were promoted for 4 of 9 (Patient #1, Patient #3, Patient #6, and Patient #7) sampled patients reviewed.

The findings included:

1. The Behavioral Health Hospital failed to ensure Patient #1 received care in a safe setting when his blood pressure readings and oxygen saturation declined over a four day period (8/13/2024 - 8/17/2024) without any documentation of notification to the physician/nurse practitioner; On 8/17/2024, Patient #1 was found unresponsive in the dayroom and staff was unable to revive him. Emergency Medical Services (EMS) was called to the Behavioral Health Hospital, transferred to a local hospital and pronounced deceased at the local hospital.

2. The faciity failed to ensure Patient #3 received care in a safe setting when she became aggressive and tried to attach staff, Registered Nurse # and Mental Health Technician # took Patient #3 to the seclusion room. The RN and MHT were viewed on video to be pushing and pulling on Patient #3 to get her into the seclusion room and close the door.

3. The facility failed to ensure Patient #6 received care in a safe setting when the patient experienced low blood pressure and low oxygen saturation over a two days (10/2/2024 and 10/3/2024) without any documentation of notification to the physician/nurse practitioner.

4. The facility failed to ensure Patient #7 received care in a safe setting when the patient's blood pressure was low and oxygen saturation unstable from 9/13/2024 - 10/14/2024 with no documentation of reassessment of the vital signs, no reassessment of the patient or notification of the physician or nurse practitioner. On 10/14/2024, the patient was found to be wheezing when in the dayroom. The patient was transferred to a local hospital and admitted with diagnosis of Pneumonia.
Refer to A-0144

Based on facility policy review, document review, medical record review, video recording review, and interview, the facility failed to ensure patients had the right to receive care in a safe setting for 4 of 9 (Patient #1, #3, #6, and #7) sampled patients.

The findings included:

1. Review of the facility's policy, "Patient Abuse or Neglect", last revised 8/2024, revealed the facility "will afford to patients the highest standards of clinical practice and human dignity. Staff members will demonstrate kindness...regardless of the patient's behavior...Inappropriate staff conduct may include, but is not limited to: Any physical violence which may result in injury such as...rough handling...Not performing duties safely..."

Review of the facility's policy, "Patient Observation Guidelines," last revised 07/2024, revealed "It is the policy of [Facility #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient's behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked..."

Review of the facility's policy "Vital Signs" last revised 11/2023 revealed, "...All patients...will have vital signs taken...as...warranted by patient's condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider..."

Review of the facility's policy, "CPR [Cardiopulmonary Resuscitation - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]", last revised 12/2023, revealed "...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression..."

2. Review of the "Patient Admission Information" form dated 8/13/2024, revealed Facility #1 is "... dedicated to providing a safe environment for its patients and staff..."

Review of the "Job Descriptions" for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to "...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you..."

3. Medical record review revealed Patient #1 was transferred from Facility #2 (a skilled nursing facility(SNF)) and involuntarily admitted to Facility #1 on 8/13/2024.

Review of the "Standardized Intake Assessment - Direct Admissions" dated 8/13/2024, revealed Patient #1 was involuntary admitted from a SNF to Facility #1. Patient #1 was referred by the SNF due to to escalating verbal and physical aggression, making sexually inappropriate comments to the staff and attempting to hit them. The intake assessment further documented the patient needed medication stabilization.

The "Psychiatric Evaluation" dated 8/14/2024, revealed Patient #1 was a 59-year-old male with Dementia and Behavioral Disturbances. The patient's chief complaint in his own words was, "I was at the nursing home and they sent me over here." The patient was oriented to person and place. The patient was very aggressive and sexually inappropriate. The patient demonstrated labile mood and behavior, temper outbursts and verbally assaulting peers. Patient #1 was confused, would forget limitations, and was a high fall risk. The patient was experiencing suicidal thoughts, and wished to be dead. He also had homicidal thoughts toward the nursing home staff and wandered into other patient's rooms, threatening them. The patient had delusions related to dementia. He has a medical history of Diabetes Mellitus, COPD (Chronic Obstructive Pulmonary Disease; a group of lung diseases that block air flow and make it difficult to breathe), Cirrhosis of the Liver, Hyperlipidemia (an excess of lipids or fats in the blood), Atherosclerosis (Atherosclerosis is the buildup of fats, cholesterol, and other substances in and on the artery walls) and a history of alcoholism and smoking. Patient #1 required assistance with ambulation, bathing, dressing and grooming and was assessed with a severe level of disability.

Review of the "High Risk Notification Alert" dated 8/13/2024 at 1:25 PM revealed Patient #1 had a medically compromised risk due to COPD. There was no documentation his oxygen saturation was assessed prior to the transfer to his assigned room.

Medical record review for Patient #1 revealed the following:

On 8/13/2024, there was no documentation the patient's O2 sat was monitored for a baseline at the time of admission. (The normal O2 sat for a healthy adult is 95% to 100%).
On 8/14/2024, at 11:06 AM - O2 sat - 91%. There was no documentation a physician or LIP (licensed independent practitioner) was notified of the below normal O2 sat.
On 8/15/2024, at 8:10 PM.- O2 sat - 79%; Blood Pressure (BP) -89/53. There was no documentation a physician or LIP was notified of the below normal BP or O2 sat.
On 8/15/2024, at 8:11 PM - BP - 92/45. There was no documentation a physician or LIP was notified of the below normal BP.
On 8/15/2024, at 8:12 PM -O2 sat - 92%; BP - 91/44. There was no documentation a physician or LIP was notified of the below normal O2 sat or BP.
On 8/15/2024, at 8:14 PM - O2 sat - 93%; BP - 88/41. There was no documentation a physician or LIP was notified of the below normal BP or O2 sat.
On 8/15/2024, at 8:20 PM - O2 sat - 94%. There was no documentation a physician or LIP was notified of the below normal O2 sat.
On 8/16/2024, at 7:13 AM - O2 sat - 90%; BP - 87/50. There was no documentation a physician or LIP was notified of the below normal O2 sat and BP.
On 8/16/2024, at 7:04 PM - O2 sat - 78%; BP - 151/119; Heart Rate (HR) - 203. There was no documentation a physician or LIP was notified of the below normal O2 sat and the elevated BP.
On 8/16/2024, at 10:26 PM - O2 sat - 78%. There was no documentation a physician or LIP was notified of the below normal O2 sat.
On 8/17/2024, at 8:00 AM - O2 sat - 84%; BP - 183/110; HR - 157. There was no documentation a physician or LIP was notified of the below normal O2 sat, elevated BP and HR.
On 8/17/2024, at 10:40 AM - BP - 183/110. There was no documentation a physician or LIP was notified of the elevated BP.

Review of the "Incident Report," dated 8/14/2024 at 10:30 PM, revealed, "This PT [Patient #1] got in another pt bed, other pt became aggressive towards this pt [Patient #1]. This pt [Patient #1] appears to have bluish-purple discoloration noted under his left eye with a small amount of blood noted to his nose..."

Review of the "Incident Report" dated 8/15/2024 at 2:50 PM, revealed, "... it was observed that [Patient #1] was agitated and put himself on the floor..." There was no documentation Patient #1 was injured during this incident.

Review of a "Nursing - Daily Progress Note 8 HR Shift" revealed the following:
"...8/17/2024 11:00 AM Patient [Patient #1] found on floor in restroom. Denies pain or discomfort. No injuries noted. MD [Medical Doctor] notified. No new orders... 8/17/2024 at 1731 [5:31 PM] Patient noted in dayroom, lethargic and SOB [short of breath] cough (non-productive) noted. Patient placed on O2 [oxygen] at 2 LBNC [liters by nasal cannula]. Stat [immediately] CXR [chest x-ray] 2-view, covid swab stat, Prednisone 30 mg [miligrams] now...Rocephin [antibiotic] 1 gm [gram] IM [intramuscularly] now. Family notified..."

Review of the "Medical Response Team Documentation" dated 8/17/2024, revealed the Medical Response Team (MRT) was initiated at 5:55 PM and first responders arrived at 6:00 PM. "... Descriptors of events up to time of call: pt [Patient #1] noted to have a congested airway and a cough with difficulty breathing. O2 started per N.P. [Nurse Practitioner] and meds [medications] ordered. Pt got worser [worse] and CPR had to be started... Early Warning Sign...Acute Mental Status Change...Change in LOC [level of consciousness]...Airway Management - ambu bag [handheld device that provides positive pressure ventilation to patients who are not breathing or not breathing adequately]...Additional notes - CPR started... MRT completed call - pt [Patient #1] transferred to [named Hospital] via ambulance... moved to higher level of care..."

Review of the "Code Blue [a hospital emergency code that indicates a patient is in critical condition and needs immediate medical attention] R.N. Documentation" dated 8/17/2024 at 5:55 PM revealed, "... Reason for code/condition of patient: Patient found unresponsive in the dayroom at 1755 [5:55 PM] unable to obtain vital signs. Unresponsive to verbal/tactile stimuli [tactile stimuli is connected with the sense of touch]. Code blue initiated and CPR started...AED [Automated external defibrillators - portable, life-saving devices designed to treat people experiencing sudden cardiac arrest] Initiated - 'yes'...AED Time started: 1757 [5:57 PM]...number of shocks delivered - 0; patient response: unresponsive, no pulse...Patient found unresponsive in dayroom at 1755 [5:55 PM]..."

Review of an "Incident Report," dated 8/17/2024 at 5:55 PM, revealed that Patient #1 was "observed in room unresponsive, no pulse and not breathing, Code MRT called and then Code Blue called, and CPR initiated immediately. 911 called continued [cpr] until 911 arrived and took over and then pt [Patient #1] was transported to [Hospital #1] by [named ambulance service]..."

Review of a "Progress Record" revealed, "... 8/17/2024 1804 [6:04 PM] Alerted to Code Blue on unit. On assessment patient [Patient #1] in recliner unconscious and chest compressions in progress. Patient assisted to floor by staff. 1810 [6:10 PM] Pulse check via AED - Rt [right] femoral [attempted to check pulse with palpation of right femoral artery] was negative; chest compressions resumed...1815 [6:15 PM] EMS arrived and took over code... 1833 [6:33 PM] 1755 [5:55 PM] patient found unresponsive in dayroom. MRT called. Code Blue initiated. Started CPR...1807 [6:07 PM] HR 126, BP - 111/71, 0 resp. 1813 [6:13 PM] - still no pulse. CPR continued. 1814 [6:14 PM] - 107 blood sugar. Paramedic arrived. 1822 [6:22 PM]- patient intubated and pupils fixed/dilated, no pulse. 1827 [6:27 PM - agonal breathing [a term for a pattern of abnormal breathing that indicates a severe medical emergency such as cardiac arrest or stroke]. 1830 [6:30 PM] - CPR continued 1832 [6:32 PM] - compressions/bagging continue and patient transported to [Hospital #1]..."

Review of the Emergency Medical Services (EMS) report dated 8/17/2024 revealed EMS arrived at the facility at 6:13 PM. The EMS report documented, "Staff advised the Pt. had been declining today and just got an order to have a chest x-ray done due to h/o [history of] COPD and CHF [Congestive Heart Failure - a chronic condition in which the heart doesn't pump blood as well as it should]."

Review of video footage, dated 8/17/2024, revealed the following:

4:22:29 PM - MHT #3 entered the Day Room and began using a dynamap (an electronic device used to take temperature, pulse, blood pressure and oxygen saturation) to assess vital signs on Patient #1, who was sitting in a geri-chair.
4:22:29 PM to 4:26:54 PM - MHT #3 moved to the right and left side of Patient #1 while removing and replacing the pulse oximeter and blood pressure cuff.
4:46:04 PM - RN #2 approached Patient #1, placed a hand on patient's shoulder and used the dynamap to assess vital signs and oxygen saturation
4:48 PM - RN #2 placed the manual BP cuff on Patient's #1's arm
4:51:30 PM - RN #5 used the dynamap to assess vital signs and placed a hand on Patient #1's chest.
4:53:46 PM - RN #5 moved to right side of Patient #1 and touched the oxygen tank, then moved to left side of patient.
5:21 PM - MHT #3 approached Patient #1 with a food tray and placed the tray on the shelf after patient shook his head. RN #2 entered and performed a nasal swab on Patient #1.
5:42:08 PM to 5:48:22 PM - x-ray personnel were in the Dayroom and performed chest x-rays of Patient #1.
6:00 PM - RN #5 entered the Dayroom and placed tingers on Patient #1's left wrist then left the room.
6:00:30 PM - RN #5 and RN #2 entered and approached Patient #1. RN #2 performed a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center of the chest of a patient who is not alert and does not respond when his/her name is called).
6:02:26 PM - The crash cart (a cart stocked with emergency medications and supplies that are used during emergency situations such as a patient not breathing) was brought into the dayroom and taken back out.
6:02:51 PM - The House Supervisor (HS) entered the hallway.
6:03:05 PM - The HS entered the dayroom.
6:03:37 PM - Patient #1 (in the geri-chair) was moved into the hallway.
6:03:56 PM - RN #2 began chest compressions on Patient #1 while he was in the geri-chair. Staff from other units arrived on the scene to provide assistance.
6:09 PM - NP #1 arrived at the code.
6:10:24 PM - RN #7 arrived at the code, Patient #1 was placed on the floor and resuscitation efforts continued.
6:13 PM - EMS arrived, and Patient #1 was loaded for transport to higher level care.

Review of the Emergency Department (ED) record from Hospital #1 dated 8/17/2024, revealed Patient #1 was seen in the ED at 6:42 PM. Patient #1, "...was brought in via EMS from [Facility #1] after found unresponsive. CPR was started on the scene per staff and continued by EMS and arrival and intubated. The cardiac monitor revealed PEA [pulseless electrical activity - a life-threatening condition where the heart has electrical activity but does not pump blood to the body] and no palpable pulse on arrival at the hospital. The patient presented with cardiac arrest from [named Facility #1]...Patient was standing, rolling [in wheelchair] at approximately 530 [PM] declined dinner and they [staff from Facility #1] went back in to check on him and he was found down, EMS arrived at 1810 [6:10 PM] started CPR initial rhythm was PEA, he received epi [epinephrine - medication given to during cardiac arrest to stimulate the heart and restore the heartbeat] x 3 [doses] and bicarb [bicarbonate - medication given during cardiac arrest to correct metabolic acidosis and improve outcomes in cardiac arrest] x 1 in the field. Patient did have a fall today and was hit in the eye yesterday. Initial rhythm here was PEA patient received Bicarb and epi was intubated and had to have IO [intraosseous - injecting fluid and medication directly into the bone marrow; used when intravenous access is not available or is not feasible] access to the EJ [external jugular - vein in the neck that drains blood from the head to the heart; may be used in an emergency situation to provide fluids to a patient who is in distress] initiallly placed by the paramedics not working...Impression: Cardiac arrest; Respiratory Arrest. Time of Death 6:49 PM."

During an interview on 9/4/2024 at 8:45 AM, RN #2 stated she worked as the charge nurse on the Geropsychiatric Unit the day [8/17/2024] of the incident involving Patient #1. When asked if Patient #1 had respiratory issues, RN #2 stated, "... he [Patient #1] had COPD. His pulse oximeter [machine used to measure oxygen saturation] reading was 94-95 before the use of the inhaler and 96-97 after use of the inhaler...didn't check his breath sounds or respiratory rate. A few hours later, the medication nurse came to the desk and told me to check on [Patient #1]. He was short of breath and wheezing. The medication nurse came to the unit about 45 minutes later and said to come with her to the day room. [Patient #1] was unresponsive in a chair with his legs propped up in another chair...called a code, and CPR was started. Before the code was started, [Patient #1]'s brother was contacted. He [Patient #1's brother] was very upset because his brother was in an altercation with another patient the previous day and had a black eye and earlier that morning, [Patient #1] was found in the floor of the hallway restroom. He was conscious and asking to get up... a lot of times when patients come out of the hall bathroom, the door may not close thoroughly and doesn't lock. No one monitors the hallway bathroom. You won't know who goes in the hallway bathroom. When [Patient #1] was found unresponsive in the day room, he was in a geri-chair [geriatric reclining chair] with his feet propped up..." When asked if she did any type of assessment of Patient #1 when he complained of shortness of breath, RN #2 reported that she, "... took his vital signs...again around 11:00 AM and they were fine..." RN #2 stated the only problem with Patient #1 at that time was his oxygen saturation was low. RN #2 stated Patient #1's oxygen saturation was in the 80s, and he was placed on oxygen.

During an interview on 9/4/2024 at 11:20 AM, the House Supervisor (HS) reported that she received a call from the nurse practitioner (no name provided) reporting that Patient #1 was having problems breathing. The HS went to the Pharmacy to pick up medication for Patient #1. When the HS arrived on the unit, there was a crash cart (cart which contains medications and supplies to respond to a medical emergency code) present. The HS stated the unit nurse had to call a code for Patient #1. The HS stated Patient #1 was sitting in a geri-chair in the dayroom with his feet elevated, and he looked like he was sleeping. The HS stated Patient #1 had no carotid (blood vessel in the neck) pulse, and the staff had initiated CPR. The HS stated she was first notified Patient #1 was having difficulty breathing around 5:30 to 5:45 PM. The HS stated she didn't know Patient #1 had been having difficulty breathing earlier in the shift. The HS stated she did not recall being notified by staff that Patient #1 had been found in the floor in the bathroom earlier on the day the patient was found unresponsive.

During an interview on 9/12/2024 at 2:05 PM, the Chief Nursing Officer (CNO) reported that the hallway bathrooms are keyed, and they have an automatic lock. The CNO stated technicians let the patients in the bathroom and monitor the door.

During an interview on 10/16/2024 at 7:50 AM, Mental Health Technician (MHT) #3, reported "... recalled working with [Patient #1] around 7:00 AM and 3:00 PM. When [named Patient #1] got up to get dressed, he was short of breath when he tried to put on his pants." When asked about his assistance with Patient #1 around 3:00 PM, MHT #3 reported, "... when he approached him [Patient #1], he [patient] had taken his oxygen off... reached for the oxygen tubing to place it on him [patient]. When he [patient] pulled the pulse oximeter off his finger and replaced it, the reading might have been too low; however, do not recall the reading or if it was too low..." When MHT #3 was asked if he recalled if he reported anything about Patient #1 to other staff at that time, MHT #3 "did not recall."

During an interview on 10/16/2024 at 8:10 AM, Nurse Practitioner (NP) #3 stated on the day (8/17/2024) of the incident, the charge nurse called her about Patient #1 being placed on oxygen. NP #3 stated the next call that she received from the nurse was to inform her that they had to perform CPR on him after he was found unresponsive. He was transferred to the hospital where he died. NP #3 stated she was never informed of the patient having a low blood pressure or low oxygen saturation at any other time during his admission at (named Facility #1).

During an interview on 10/16/2024 at 8:30 AM, NP #1 reported she was working on the Gero unit on the day (8/17/2024) of the incident with Patient #1. NP #1 stated when she arrived on the unit, the staff was performing chest compressions while the patient was sitting in the geri-chair. NP #1 stated that after another nurse arrived, they were able to get Patient #1 on the floor, a hard surface, so that more effective chest compressions could be performed.

During an interview on 10/16/2024 at 10:11 AM, RN #7 reported that when Patient #1 was found unresponsive, she responded to the Code Blue when it was called. RN #7 stated when she arrived on the Gero unit, staff was performing chest compressions while Patient #1 was in the geri-chair. RN #7 stated she got LPN #1 to assist with getting the patient in the floor so CPR could be continued.

During an interview on 10/16/2024 at 1:30 PM, RN #5 reported that it was about 4:00 PM, when she was doing accuchecks (fingersticks to check a patient's blood sugar) in the dayroom. RN #5 stated no one communicated anything to her about Patient #1. RN #5 stated she took Patient #1's vital signs at 4:51 PM because the dynamap didn't register appropriately. RN #5 stated she tried to arouse Patient #1 at 6:00 PM, but he did not respond. RN #5 attempted to check his pulse and went to inform the charge nurse that he was unresponsive. RN #5 stated she and RN #2 returned and moved Patient #1 out into the hall and began chest compressions. RN #5 stated RN #2 was directing the code.

During an interview on 10/18/2024 at 9:45 AM, when questioned about documentation that Patient #1 had an oxygen saturation of 78% on 8/17/2024, LPN #3 stated that she did not recall Patient #1 having an oxygen saturation of 78%. LPN #3 stated she did not recall notifying a medical provider or NP that Patient #1 had complaints of shortness of breath, low oxygen saturations or abnormal vital signs. LPN #3 confirmed that when MHTs made rounds, they were to check the patients for breathing, safety and make sure nothing concerning was going on with them.

During an interview on 10/18/2024 at 10:15 AM, RN #3 stated the MHTs and CNAs taking vital signs wee supposed to scan the patients' bar code prior to taking the vital signs. Once the vital signs were taken with the dynamap, they are transferred in the system and to the patients' record. The vital signs were also recorded on a log which is given to the nurse. If there was a need for vital signs to be retaken, those vital signs should also be in the system. RN #3 stated she did not recall ever having to notify a NP or MD regarding issues with Patient #1. RN #3 stated the Milieu Supervisor (MS) #1 reported that Patient #1 fell on the Friday before he died on Saturday. RN #3 stated no one had to report it to the nurse because he fell in front of the nurse's station. RN #3 stated Patient #1 complained of not feeling good when he arrived at the nurses' station. RN #3 stated the charge nurse (RN #6) told a staff member to take Patient #1 back to his room and have him lie down. RN #3 stated RN #6 never wrote an incident report, called the physician, or assessed Patient #1 after the fall.

During an interview, on 10/30/2024 at 7:30 AM, MS #1 reported that she had received complaints from the CNAs and MHTs about RN #6. MS #1 stated the CNAs and MHTs reported that when they told RN #6 about mental status changes, breathing problems, increased temperature, or vital sign changes, she would not address the concern, and she would tell her superiors that staff never reported anything to her. MS #1 reported that Patient #1 fell in front of the nurses' station on the Friday (8/16/2024) before he died, but she did not think anything was done about the fall. MS #1 stated Patient #1 was yelling and complaining of pain after the fall.

During an interview on 10/30/2024 at 10:34 AM, RN #6 reported that when the MHTs and CNAs report abnormal vital signs to her, then she would give a copy of the abnormal vital signs to the medication nurse who typically documented the vital signs. RN #6 stated they might do a quick assessment and recheck the vital signs with the dynamap and manually. RN #6 stated when there are abnormal vital signs, she (RN #6) would ask the medication nurse and the technicians to check on the patient more frequently. When asked who would call the medical providers to report abnormal vital signs, RN #6 stated she usually placed the calls. RN #6 stated she does not usually review the patients' charts, however; she "...try to check the vital signs when I have time. Some days are just wild. RN #6 stated that they have parameters for reporting abnormals, but if the patient was not symptomatic, she would call the nurse practitioner who would likely send the patient to the emergency room. RN #6 stated if the patient was symptomatic, she would call the medical response team and then the doctor.

4. Medical record review revealed Patient #3 was admitted to Facility #1 on 7/27/2024 with diagnoses which included Schizoaffective Disorder, Depression, and Other Stimulant Dependence.

Patient #3 was voluntarily admitted to the facility and presented with suicidal ideations with no plan to commit suicide, history of physical and sexual childhood abuse, and a history of domestic violence. Patient #3 reported hearing voices telling her people were out to get her, saw things that were not there, increased anger/irritation, impulsiveness and substance abuse. Patient #3 was assessed as a danger to self and others as evidenced by family member completion of suicide (cousin), poor judgment, poor insight, and poor impulse control.

Review of a "Progress Note" dated 8/9/2024 at 11:06 PM, revealed, "... Pt psychotic and aggressive...shortly after arriving to unit, pt tried attacking staff. After pt was able to calm down she was placed in seclusion at 2306 [11:06 PM]. At 0221 [2:21 AM] pt was able and willing to verbally contract for safety and therefore was taken back to her room..."

Review of a "Seclusion/Restraint/Chemical Restraint Order" dated 8/9/2024 at 11:06 PM, revealed, "...type of intervention: Seclusion...Reason for intervention - Imminent Danger to others: Patient attacking staff...Less Restrictive Interventions: Verbal Des-escalation/redirection...Reality orientation..."

Reveiw of the "Post Intervention Face to Face Evaluation" dated 8/9/2024 at 11:48 PM, revealed, "...Assessment of immediate situation: Pt standing in seclusion. Pt refusing to speak...Describe the patient's response to intervention...Pt in acute psychotic episode...Mental Status/Behavioral Assessment: Thought process - flight of ideas... loose associations... circumstantial...Mood - Angry, irritable...Affect...Labile...Behavior...Uncooperative... Attitude...Belligerent...Motor Active...Increased;... Thought content: Delusions... Delusional psychotic Behaviors..."

Review of the "Investigation Summary" revealed that on 8/9/2024 at 11:06 PM, revealed that during review of the video footage, RN #4 and MS #2 were seen pulling and pushing Patient #3 into the seclusion room so the door could be closed. Patient #3 was in seclusion from 11:06 PM to 2:21 AM, a total of 3 hrs and 15 minutes.

During an interview on 9/12/2024 at 1:30 PM, the Director of Risk Management (DRM) reported that she reviewed the video and interviewed staff to investigate this incident. The DRM stated the video footage revealed MS #2 and RN #4 pushed and pulled Resident #3 into the seclusion room to get her into the room and closed the door. The DRM stated MS #2 was suspended pending the results of the investigation and RN #4 received a written warning and was required to attend a Handle with Care training class prior to returning to work.

During an interview on 9/12/2024 at 2:05 PM, the CNO reported that she watched the video footage of the incident and participated in the discussion and interviews. The CNO stated it was an administrative decision that MS #2 would be terminated from employment. The CNO stated RN #4 got a final written warning for pulling the patient into the room.

During an interview on 10/14/2024 at 11:00 AM, DON #3 confirmed during the review of the video footage, that MS #2 and RN #4 did not handle Patient #3 according to Restraint/Seclusion/Handle with Care/De-Escalation Policy.

During an interview on 10/14/2024 at 11:15 AM, the CNO confirmed during the review of the video footage that RN #4 was pulling and pushing on Patient #3, and did not follow the facility's policies for Restraint/Seclusion/Handle with Care.

During an interview on 10/15/2024 at 7:50 AM, RN #4 reported that she and MS #2 gently assisted/escorted Patient #3 into the seclusion room on 8/9/2024. RN #4 denied that she pulled or pushed Patient #3 into the seclusion room.

5. Medical Record review for Patient #6's revealed an admission date of 10/1/2024 with diagnoses that included Vascular Dementia, Behavior Disturbance, Mood Disturbance and Anxiety.

Review of the "Psychiatrist Evaluation/Admission History and Examination" revealed, "...history of present illness (onset of illness and circumstances leading to admission) - 81 yo [year old]... with dementia presents with paranoia, agitation, labile mood & [and] behavior... poor insight & judgement, forgets limitation... Recently discharged & admitted to medical hospital for AKI [Acute Kidney Injury]... Medical history... Acute on Chronic CHF [Congestive Heart Failure], HTN [Hypertension], Hypothyroidism, HLD [Hyperlipidemia]..."

Review of vital signs for Patient #6 revealed the following oxygen saturation levels [O2 sats]:
On 10/2/2024 at 11:19 AM, O2 sat - 89%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.
On 10/3/2024 at 11:19 AM, O2 sat - 89%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.
On 10/3/2024 at 11:19 AM, O2 sat - 90%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.

6. Medical Record review for Patient #7 revealed an admission date of 9/25/2024 with diagnoses of Psychosis, History of Hypothyroidism, Cerebrovascular Accident, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Rule Out Early Dementia.

Review of Patient #7's vital signs revealed the following:
On 9/27/2024 at 1:03 PM - BP - 89/50; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.
On 9/28/2024 at 11:35 AM - BP - 80/44; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.
On 9/13/2024 at 8:37 AM - BP - 87/54, O2 sat - 92%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP.
On 9/13/2024 at 10:48

Based on policy review, document review, review of video footage, medical record review, and interview, the behavioral health hospital failed to provide Nursing services to meet the patients' needs and ensure patients received necessary care and services for 4 of 9 (Patient #1, #3, #6, and #7) sampled patients who experienced a decline in their vital signs and the physician and/or nurse were not notified, assessments and reassessments were not performed by staff when patients experienced a decline in their vital signs, and when staff handled patients aggresively when escorting patiens to the seclusion room.

The findings included:

1. The behavioral health hospital failed to notify the physician/nurse practitioner of Patient #1's decreased blood pressure and oxygen saturation for a four-day. On the fourth day (10/17/2024), the patient was up in a geri-chair in the dayroom when he was found unresponsive. The nursing staff was unable to revive Patient #1 after cardiopulmonary resuscitation was started. Emergency Medical Services were called and the patient was transported to the local hospital where the patient was pronounced deceased.

2. The behavioral health hospital failed to ensure Patient #3 was allowed to go into the seclusion room under her own willpower after she was aggressive and was hitting at staff. The Registered Nurse and Mental Health Technician were viewed on video to push and pull-on Patient #3 to make her go into the seclusion room.

3. The behavioral health hospital failed to notify the physician/nurse practitioner of Patient #6 and Patient #7's decreased blood pressure and oxygen saturation. Patient #7 was transferred to a local hospital after developed wheezing. Patient #7 was admitted to the hospital with a diagnosis of Pneumonia.

Refer to A-115, A-144, and A-395

Based on facility policy review, document review, medical record review and interview, the hospital failed to provide Registered Nurse (RN) supervision and oversight to evaluate the care provided to the patients and their response to treatment for 4 of 9 (Patient #1, #3, #6 and #7) sampled residents.

The findings included:

1. Review of the hospital's policy, "Patient Observation Guidelines," last revised 07/2024, revealed "It is the policy of [Hospital #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient's behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked..."

Review of the hospital's policy "Vital Signs" last revised 11/2023 revealed, "...All patients...will have vital signs taken...as...warranted by patient's condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider..."

Review of the hospital's policy, "CPR [(Cardiopulmonary Resuscitation) - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]", last revised 12/2023, revealed "...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression..."

2. Review of the "Patient Admission Information" form dated 8/13/2024, revealed Hospital #1 is "... dedicated to providing a safe environment for its patients and staff..."

3. Review of the "Job Descriptions" for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to "...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you..."

4. Medical record review revealed Patient #1 was transferred from a skilled nursing facility(SNF) and involuntarily admitted to Hospital #1 on 8/13/2024.

Patient #1 experienced the following while at Hospital #1:

On 8/13/2024, there was no documentation the patient's O2 sat was monitored for a baseline at the time of admission. (The normal O2 sat for a healthy adult is 95% to 100%).
On 8/14/2024 at 11:06 AM - O2 sat - 91%. There was no documentation of a reassessment by a nurse or physician or licensed independent practitioner (LIP) notification of the below normal O2 sat.
On 8/15/2024 at 8:10 PM.- O2 sat - 79%; Blood Pressure (BP) -89/53. There was no documentation of a reassessment by a nurse or a physician or LIP notification of the below normal BP or O2 sat.
On 8/15/2024 at 8:11 PM - BP - 92/45. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 8/15/2024 at 8:12 PM -O2 sat - 92%; BP - 91/44. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat or BP.
On 8/15/2024 at 8:14 PM - O2 sat - 93%; BP - 88/41. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP or O2 sat.
On 8/15/2024 at 8:20 PM - O2 sat - 94%. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.
On 8/16/2024 at 7:13 AM - O2 sat - 90%; BP - 87/50. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat and BP.
On 8/16/2024 at 7:04 PM - O2 sat - 78%; BP - 151/119; Heart Rate (HR) - 203. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat and the elevated BP.
On 8/16/2024 at 10:26 PM - O2 sat - 78%. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.
On 8/17/2024 at 8:00 AM - O2 sat - 84%; BP - 183/110; HR - 157. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat, elevated BP and HR.
On 8/17/2024 at 10:40 AM - BP - 183/110. There was no documentation of a reassessment by a nurse or physician or LIP notification of the elevated BP.

Review of the hospital's "Medical Response Team Documentation" dated 8/17/2024, revealed the Medical Response Team (MRT) was initiated at 5:55 PM and first responders arrived at Hospital #1 at 6:00 PM due to a distress call for Patient #1 and documented. "... Descriptors of events up to time of call: pt [Patient #1] noted to have a congested airway and a cough with difficulty breathing. O2 started per N.P. [Nurse Practitioner] and meds [medications] ordered. Pt got worser [worse] and CPR had to be started... Early Warning Sign...Acute Mental Status Change...Change in LOC [level of consciousness]...Airway Management - ambu bag [handheld device that provides positive pressure ventilation to patients who are not breathing or not breathing adequately]...Additional notes - CPR started... MRT completed call - pt [Patient #1] transferred to [named Hospital] via ambulance... moved to higher level of care..."

5. Medical record review revealed Patient #3 was admitted to Hospital #1 on 7/27/2024 with diagnoses which included Schizoaffective Disorder, Depression, and Other Stimulant Dependence.

Patient #3 was voluntarily admitted to the hospital and presented with suicidal ideations with no plan to commit suicide, history of physical and sexual childhood abuse, and a history of domestic violence. Patient #3 reported hearing voices telling her people were out to get her, saw things that were not there, increased anger/irritation, impulsiveness and substance abuse. Patient #3 was assessed as a danger to self and others, poor judgment, poor insight, and poor impulse control.

Review of the "Investigation Summary" revealed that on 8/9/2024 at 11:06 PM, revealed that during review of the video footage, Registered Nurse (RN) #4 and MS (Milieu Supervisor) #2 were seen pulling and pushing Patient #3 into the seclusion room so the door could be closed. Patient #3 was in seclusion from 11:06 PM to 2:21 AM, a total of 3 hrs and 15 minutes.

6. Medical Record review for Patient #6's revealed an admission date of 10/1/2024 with diagnoses that included Vascular Dementia, Behavior Disturbance, Mood Disturbance and Anxiety.

Review of vital signs for Patient #6 revealed the following oxygen saturation levels (O2 sats):
On 10/2/2024 at 11:19 AM, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or Licensed Independent Practitioner (LIP) notification of the below normal O2 sat.
On 10/3/2024 at 11:19 AM, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.
On 10/3/2024 at 11:19 AM, O2 sat - 90%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.

Review of the results of a Complete Blood Count (CBC) with Differential (a blood test that measures the number and types of different blood cells in the body) collected 10/8/2024 revealed Patient #6's white blood count was 2.2 (normal range is 4.0-11.0) and Absolute Neutrophils (this type of white blood cell helps the body fight infection and heal wounds) was 0.0 (normal range is 1.8-7.0). Patient #6 was transferred to an acute care hospital where she was admitted with a diagnosis of Neutropenia (a condition where the absolute neutrophil count is low) and Acute Kidney Injury (a condition that occurs when kidneys suddenly lose their ability to filter waste from the blood, developing within hours or days).

7. Medical Record review for Patient #7 revealed an admission date of 9/25/2024 with diagnoses of Psychosis, History of Hypothyroidism, Cerebrovascular Accident, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Rule Out Early Dementia.

Review of Patient #7's vital signs revealed the following:
On 9/27/2024 at 1:03 PM - BP - 89/50; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 9/28/2024 at 11:35 AM - BP - 80/44; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 9/13/2024 at 8:37 AM - BP - 87/54, O2 sat - 92%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat.
On 9/13/2024 at 10:48 AM - BP - 85/47, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat..
On 10/12/2024 at 3:55 PM - O2 sat - 93%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat..
On 10/13/2024 at 1:48 PM - O2 sat - 94%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat..
On 10/14/2024 at 7:36 AM - BP - 73/47; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 10/14/2024 at 7:39 AM - BP - 73/48; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 10/14/2024 at 7:39 AM - BP - 74/48, O2 sat - 91%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat..
On 10/14/2024 at 7:40 AM - BP - 78/51, O2 sat - 90%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat.
On 10/14/2024 at 10:56 AM - BP - 77/46; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP.
On 10/14/2024 at 11:46 AM, Patient #7 was in the dayroom and found to be wheezing, BP - 95/57, heartrate (HR) - 65, respirations (R)- 17, and temperature (T) - 99.9. Patient #7 was transferred to the hospital. The "Physician Discharge Order Discharge Plan" revealed the outcome from his hospitalization was limited due to medical decline. Patient #7 was admitted to a local hospital with a diagnosis of pneumonia.

Refer to A-144