HospitalInspections.org

482.13(c)(2) Patient Rights: Care in Safe Setting

A0115

Based on a comprehensive review of medical records, facility documents, staff interviews, and video footage, it was determined that the facility failed to protect and prevent the death of one patient as evidence by: not implementing necessary measures to ensure patient safety (A0144). This failure resulted in Patient #1 ingesting crack cocaine laced with fentanyl, which caused physical harm. This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.

Based on findings from interview and video review the hospital failed to implement measures to ensure the safety of patients entering the Crisis Stabilization Unit (CSU) for 1 of 10 patients reviewed. This resulted in Patient #1 bringing in contraband/drugs, consuming it on the unit, and dying. It was later determined Patient #1 consumed crack/cocaine with Fentanyl (A potent opioid pain medication). Patient 1 was brought to the Emergency Department (ED) by ambulance for chief complaint of suicidal ideation. Patient #1 was examined by a provider in the ED and a mental health consultation was ordered. Patient 1 was transferred to the CSU at 6:00 pm.

Findings include:

-During interview on 2/12/2025 at 11:15 am Staff Member U (cross trained as a Tech on CSU) stated they were helping out on CSU and offered to do the intake on Patient #1 because other staff were busy with patients. Staff Member U met Patient #1 in the Sallyport, took their belongings and walked Patient #1 to their room.

-Staff Member U stated when at the room with Patient #1, the patient seemed unpredictable so Staff Member U stood in the doorway and watched Patient #1 changing with peripheral vision. Staff Member U (Tech) did not look at Patient #1 while they changed. Staff Member U acknowledged that they are required to have direct sight of patient when they are changing, and not to leave the patient.

Patient #1 had long johns on and refused to take them off. Staff Member U left the patient to ask another staff member if Patient #1 could keep them on. When Staff Member U returned to Patient #1's room, the patient had taken off the long johns clothing and was in scrubs. Staff Member U took the long johns clothing out of the room. Surveyor asked Staff Member U if they let the nurse know prior to leaving the unit that Patient #1 was not appropriately monitored during the changing of street clothes into scrubs. Staff Member U stated they meant to and forgot.

-Review of video for the evening of 2/1/2025, showed Patient #1 coming into the Sallyport with security and ED staff, Staff Member U met them in the Sallyport at 6:00 pm on 2/1/2025. Security and Emergency Department (ED) staff left. Staff Member U oversaw Patient #1 take off their outside clothes, sweatshirt, hat, and empty their pockets. Patient #1 was then escorted to their room by Staff Member U. Staff Member U was observed standing at Patient #1's door looking back and forth, not keeping direct sight on Patient #1 during the clothes change. Staff Member U can be observed leaving the room with Patient #1's clothes in their hand. Patient #1 was observed going into the bathroom wearing scrubs. Staff Member U returned to Patient #1's room and retrieved the long johns. Patient #1 came out of the bathroom and returned to their room.

-At 10:05 pm, Staff Member R (Tech), is observed looking into Patient #1's room and quickly went to the nurse's station. Staff Member T (RN) came out into the hall, Staff Member R left the CSU and returned to CSU with a Security Guard. At 10:06 pm Patient #1 came out of their room unsteady on their feet, wrapped in a blanket, and holding a white substance in their hand. Patient #1 proceeded to lay their blanket on the floor and was crushing the white substance and throwing it around the blanket. Shortly after, multiple Security Guards and other staff arrived on the unit. At 10:08 pm Patient #1 was observed putting something in their mouth and immediately after, at 10:08 pm, Patient #1 is sitting down on the blanket. Staff are around the patient, there is a white barrier of white powder around Patient #1. Patient #1 is then seen laying down at 10:10 pm, a Security Guard is holding Patient #1's head. Patient #1's body can be seen jerking. Staff Member's P (Provider) and V (RN) arrive on the unit at 10:10 pm. Staff Member V left and came back with a stretcher. Patient #1 was lifted onto the stretcher and taken to the main ED.

-Interview with Staff Member T, on 2/12/2025 at 10:15 am stated they were concerned because they didn't know what the white substance was. Patient #1 was throwing it around and yelling "do you want to die."

-Interview with Staff Member N (Security Guard), on 2/11/2025 at 1:32 pm, stated "we can't do anything until nursing gives the go ahead. There were white powder/chunks all over, we didn't know what the white substance was, which was a concern. We later found out it was crack/cocaine with Fentanyl".

-Interview with Staff Member P, on 2/11/2025 at 3:10 pm stated "There was concern about what the white substance was. Fortunately, we were masked and gloved".

The substance was tested by the Glens Falls Police Department and determined to be crack/cocaine with Fentanyl.

-Interview with Staff E (Tech) on 2/10/2025 at 10:50 am stated that there have not been any changes or any re-education since the incident with Patient #1.

Interview with Staff Member A on 2/11/2025 at 3:57 pm stated that there have not been any changes to the intake process since the incident with Patient #1. "Other than the staff leaving for that short time I don't think they did anything wrong". Staff Member A stated when they move to the new unit things will be different, more staff, two RNs to monitor when patients are changing into scrubs. The CSU will follow the intake process that is used on the inpatient behavioral health unit, which is 2 RN's monitoring the patient during clothes change under direct supervision.

-Interview with Staff Member T, on 2/12/2025 at 10:15 am stated there have not been any changes or re-education since the incident with patient #1.

- Interview with Staff Member Z on 2/10/2025 at 4:10 pm stated there have not been any changes or re-education made to the intake process since the incident with patient #1.

- Additional video was reviewed of admissions for the previous 24 hours on 2/19/2025. Staff Members I (Tech), X (RN) and Z (RN) were all signed off as having been educated on the intake process for CSU. The above staff were able to verbalize the process. The video of these staff showed a patient who was admitted to the CSU who came in from the main ED (already in scrubs) was left in their room before being searched. There was another patient who came in and was large in stature so the patient needed to wear two hospital gowns, as the hospital scrubs would not fit this patient. The patient was left with the ties on the gowns which creates a safety ligature risk. Another patient was viewed on the video, who was admitted to the CSU. When this patient was brought to their room, staff left the patient alone in their street clothes. Staff Member A confirmed that the patient should be re-searched, the ties cut off the gown and the patient should not have been left alone with street clothes on.