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Based on clinical record review, hospital staff written/typed statements, staff interviews and policy review, the facility failed to ensure Registered Nurses (RNs) and nursing staff supervised, evaluated and monitored the breathing efforts during the night time hours (12:00 a.m. to 6:00 a.m.) for three (3) of three (3) patient records reviewed. Patient #1 was found dead on 01/07/11 at 05:45 a.m. by Mental Health Technician (MHT) #2. Patient #1 was not monitored for possible medication side effects of the antipsychotic drug Perphenazine (brand name Trilafon) during the hours of 12:00 a.m. to 5:45 a.m. of 01/07/2011, the morning of her death. Perphenazine was added to present medication regime four (4) days before her death. Patient #1 was not monitored for post transfusion side effects from two (2) Units of packed red blood cells she received during the hours of 12:00 a.m. until 5:45 a.m., five (5) days prior to her death. The cumulative effect of these systemic problems resulted in the facility's inability to ensure their patients were alive and well during rounds made by nurses and nursing staff. Patient #1 was found unresponsive by facility staff at 05:45 a.m. on 01/07/2011.

FINDINGS INCLUDE:

Record review revealed that Patient #1, a 42-year old female, was admitted to the Behaviorial Health facility on December 29, 2010 at 16:58 (4:58 p.m.). Admission diagnosis was Unspecified Schizophrenia. Secondary diagnoses included: Sickle-Cell Disease; Hemoglobin Sickle Cell Disease with Crisis, Anemia Unspecified, Purpura and Other Hemmorrhagic Conditions; Thrombocytopenia Unspecified, Unspecified Disorder of Kidney and Urether, and Candidiasis of Vulva and Vagina. On December 30, 2011 she was found to be in Sickle Cell Crisis (SCC) and extremely Anemic. Complete Blood Count (CBC) obtained on 12/29/10 revealed Hemoglobin (HBG) 6.1 (Reference Range 12.0 to 16.0), and Hematocrit (HCT) 18.1 (Reference Range 35.0 to 47.0). She was then transferred to the Medical unit of the Hospital for a short stay to receive treatment. Patient #1 stayed in the medical unit for two (2) days, received two (2) Units of Packed Red Blood Cells and was then transferred back to the Behaviorial Health part of the hospital on 01/01/2011 to continue her original psychiatric treatment.

During an interview on 01/28/11 at 11:00 a.m. RN #1 stated that on the morning prior to Patient #1's death (01/07/2011) she did not go into the patient's room from 12:00 a.m. to 5:45 a.m. to observe the patient's respiratory status. The RN stated, "We just make sure they're in the room. We monitor behaviors."

During an interview on 01/28/10 at 12:30 p.m. Physician #1 stated that it is the understanding of the hospital nursing staff to monitor patient behaviors. He stated, "I don't want my patients woke up during the night because they need undisturbed sleep. I feel a good night's sleep is very important in recovery and handling their behaviors." In a typed statement dated 01/28/2011 the physician wrote, "The implied understanding of 15 minute observation checks is to ascertain the location and general behavior of our patients. The 15 minute check are not necessarily done on the quarter hour but within the 15 minute time frame. It is also the implied understanding and knowledge of unit personnel at night to be as inobtrusive as possible so as not to disturb the patient's sleep."

On 01/28/11 at 2:30 p.m. an interview with the facility's Clinical Program Director (CPD) revealed that on 01/06/11 two (2) RNs called in sick for the 7:00 p.m. to 7:00 a.m. shift. The shift was covered by RN #1, who revealed that she had not been orientated to work the Adult Psychiatric Unit (APU). The other nurse covering the shift, LPN #2, was pulled from the medical/surgical floor in the main part of the hospital. Licensed Practical Nurse (LPN) #2 revealed she was not oriented to work the APU.

Review of Psychiatric Progress notes written by the Program Medical Director (MD #1) on Patient #1 revealed the following note dated 01/06/11 which revealed the medications Patient #1 was on the morning of her death (01/07/2011):
"Effexor XR 75mg (milligram) 3 po (by mouth) q (every) am
Hydrea 500 mg po bid (two (2) times a day)
Narco 10mg/325mg po q 4-6 hrs (hours) prn (as needed) pain
Neurontin 600 mg po tid (three (3) times a day)
Prevacid 30 mg po q am
Restoril 30 mg po q hs (hour of sleep)
Seroquel 800 mg po q hs
Trilafon 8 mg po bid"

Review of the "Every 15 minute bed checks" form that the MHT's documented for Patient #1, #2 and #3's work sheets, revealed that the patient's respiratory status was not assessed on 01/06/11 from 7 p.m. to 7 a.m. During an interview on 01/28/11 at 4:30 p.m. with the DON and CPD confirmed that the observation sheets showed that no 15 minute checks were done assessing the respiratory status of patients.

Review of Patient #1's Nurses Notes (NN) revealed a Late Entry NN documented on 01/07/11 at 3:07 p.m. by LPN #1. The NN revealed, "Late Entry Approximately 05:50 a.m. Patient #1 was found dead in her hospital bed. (MHT #2) stated, 'Pt. (Patient) is not responding she won't wake up.' Upon entering pt's room noted that pt. was in bed lying on left side in fetal position, not responsive to verbal or physical stimuli. Unable to palpate carotid or peripheral pulse. Immediately called for staff to call a Code Blue and 911. (LPN #2) called a Code Blue overhead in house and 911. Removed pt. from bed placed on floor started CPR (CardioPulmonary Resuscitation)/chest compression procedures implemented."

On 01/28/11 at 3:00 p.m. an interview with the CPD revealed that after the death of Patient #1 she met with hospital administration. They all came together and had a discussion concerning the death of Patient #1. The following documentation regarding the patient's death at 05:45 a.m. on 01/07/2011 was provided by the facility:
"1-7-2011
Debriefing on the death of a patient

Attendance: (LPN #1), (MHT #1), (LPN #2), (MHT #2), (RN #1), CPD, APD, Director, Ward Clerk, (RN #4), (RN #5). *CNA (Certified Nurse Assistant) from East Campus went to SCU (Surgical Care Unit) instead of Adult Psychiatric Service (APS) unit as scheduled.

Incident: Charge Nurse - RN #1

MHT (#1) reported "I went into the room to check on patient (#1) at or around 5:00 am. She was in the same position so I turned on the light. I watched for a minute and she looked like she was breathing to me. I didn't check her at 5:15 am or 5:30 am."

MHT (#2) stated, "I went into patient's (#1) room around 5:45 am to get vital signs. I called her name but got no response. I shook her and called her name again but still no response. I immediately ran out into the hall and called for (RN #1) reporting no response from patient. (RN #1) entered the room and took over efforts to revive the patient."

(LPN #1) stated, "Upon entering the room to assist with CPR was instructed to call the code and the Ambulance." (LPN #1) revealed this was done immediately then she returned to the patient's room to assist with the code.

(RN #1) stated, "(MHT #2) called me from the patient's door indicating the patient was not responsive. I entered the room and got no response. I asked Nurse to call the Code Blue and 911. Immediately put patient on the floor and began CPR efforts. Then (RN #4), (RN #5), (LPN #2), (MHT #2), (LPN #1) began assisting in CPR efforts. Automatic External Defibrillator (AED) was used and it continued to direct us to continue CPR efforts. The ambulance arrived and they took over CPR directives. I continued to assist as directed. We were never able to get a response from patient throughout the entire CPR efforts. [Dr. (Doctor)#1] was contacted by (RN #5) as well as the family. I then contacted CPD to advise her of the patient status."

[Emergency Van Service (EVS) #1] stated, "I responded to the code blue to see if I could be of assistance. Upon entering the room I assisted in getting Oxygen (O2) concentrator hose loose. I had to go get scissors for nurse to cut the tubing lose. I also held the IV (intravenous) fluid bag as directed by the nurse."

(RN #5) stated, "I responded to an overhead page for a Code Blue on APS. I brought the AED with me in route to the code. On arrival to the patient's room patient was already placed on the floor in preparation of CPR. Efforts to revive patient were under way upon my arrival. AED was placed on patient and we continued to do CPR under the directive of the AED instruction. No shock was ever sent but continued to direct us to continue CPR. We attempted to use oxygen canister but the first one was empty and someone had to run get another one. Also had problems getting the tube loose on the O2 concentrator. We used scissors to get this loose. We continued until Medstat EMS entered room and took over efforts. At that time I immediately contacted (Dr. #1) and then contacted the family and asked them to come to Hospital ER (Emergency Room) because that is where I thought the body would be taken. Instead the family showed up here (Hospital Behavioral Unit)." END OF DOCUMENT

On 01/28/11 the CPD provided a document that was made mandatory for all facility personnel to review after the death of Patient #1. The following is the document as it appeared:

"What could have we done better?
1. 15 minute checks - Not only reassuring patient is in her bed but also that she is breathing.
2. Better job in noting patient is breathing during 15 minute checks. (example - watch for breathing or movements, touch bottom of foot to see if moves, turn on top light, call patients names, shake patient for response if other efforts have failed.)
3. Equipment - would have liked to have had an actual crash cart here. At the least all of the equipment needed like tubing should have all been together in a kit.
4. Oxygen tanks need to have a sticker to indicate when they are empty.
5. O2 concentrator needs to not have tubing zip tied up.
6. We need a log on each unit with AED showing AED battery is checked daily.
7. Sister should not have been allowed to come to the unit while we were still working with EMS and the patient. Family members should have been requested to have a seat in the lobby until someone could meet with them to give more information.

What went well?
1. Immediate response to code blue by staff.
2. CPR efforts were started immediately.
3. AED was obtained and used as trained.
4. Medstat EMT's response was quick.
5. Code Blue was paged immediately.
6. Ambulance contacted immediately.
7. Dr (Physician #1) was contacted as well as CPD.
8. CPD left message on voicemail for DON (Director of Nursing) to advise of status of the patient.
9. DOAS (Director of Acute Service) was advised of the situation and came over as administrative support.
10. Unit doors were shut off so other patients could not walk down hall while efforts were on to revive patient.
11. All other patients were escorted to the day area on APS and C shift (3-11) MHT (#1) present with those patients."
END OF DOCUMENT

On 01/28/11 at 4:00 p.m. RN #1 was interviewed. She stated that she was Charge Nurse on the 7pm-7am shift on 01/06/11 (the night Patient #1 died). She stated she worked on the Adult Psychiatric Unit (APU) 01/07/11 on the 7 p.m. to 7 a.m. shift because the unit was short. She said she started working at the hospital around 02/02/2010 and that she was responsible for assessing patients and the LPN gave all the medication. RN #1 stated that in her initial orientation she worked with RN #2 and usually worked the CDU (Chemical Dependence Unit). RN #1 confirmed that she worked with Licensed Practical Nurse (LPN) #1 on the 7pm to 7am shift 01/06/2011. She stated that there was not any specific time to document. Usually an initial assessment was done, then if anything doesn't happen you don't have to document again. RN #1 denied getting any type of verbal or written report about Patient #1's medication regime or her earlier blood transfusion prior to starting her 7p.m. to 7 a.m. shift. RN #1 stated that when she first started working at the facility she worked with RN #2 one (1) time a month. "I just learned the ropes of what goes on." When asked about the 01/07/2011 incident she stated, "Patient #1's body was stiff. We were unable to get air into her. The O2 tank was empty and there was not an AED on APS unit. When the code was called someone else brought the AED over." RN #1 stated that she was unaware of who was to check equipment. She stated, "The last time I saw (Patient #1) was around 5:00 a.m. I think. I did not see her breathing, just saw her in her room. I did not know about her having Sickle Cell Anemia or that she had received blood transfusions on December 30th (2010)." When questioned about what medication Patient #1 had been taking, the RN revealed that she was unaware of Patient #1's medication regime. "On the night shift we observe only behaviors. The MHTs document patient where-abouts every 15 minutes around the clock."

On 01/28/11 at 5:00 p.m. LPN #1 stated that she came in early to assist
with charting on the morning of Patient #1's death. "They were short,
because two (2) nurses called in. We checked the AED and O2 tanks daily
to ensure they were present and working. I always look at the patient's
breathing status when I make rounds. I didn't get a good look at (Patient #
1) because I didn't get there until 5:00 a.m."

On 01/28/11 the CPD documented the termination of MHT #1 for falsifying Patient #1's observation flow sheet. The documentation stated:
"STATEMENT
On the morning of Friday, January 7, 2011 CPD of (hospital) asked Mental Health Technician (#1) for the 15 minutes log sheets on the patients she was responsible for observing and documenting their status. (MHT #1) produced the logs and on each log there was no documentation of the 5:15 a.m. and 5:30 a.m. time slots. (MHT #1) stated, 'I went into the room to check on (Patient #1) at or around 5:00 a.m. She was in the same position so I turned her at 5:15(a.m.) or 5:30 (a.m.).' When questioned why she did not perform the checks on the patients she was responsible for, including (Patient #1), she said, 'I went to the back to get ice.' When questioned why she did not ask another staff member to perform the observations and documentations before leaving the unit (MHT #1) did not respond. It is standard practice to ask another staff member to perform the patient observations and documentation if it is necessary for the assigned staff member to leave the unit. (MHT #1) placed a "0" in the 5:15 a.m. and 5:30 a.m. slots prior to giving the logs to the CPD. The CPD placed the logs in the respective charts."

On 01/31/11 at 10:45 a.m. the DON was asked for an insert from their pharmacy on the medication Trilafon (Perphenazine). The DON provided the following documentation which had been down-loaded from .
"Important Warning Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as perphenazine have an increased chance of death during treatment.
Perphenazine is not approved by the Food and Drug Administration (FDA) for treatment of behavior problems in older adults with dementia. Talk to the doctor who prescribed this medication if you, a family member, or someone you care for has dementia and is taking perphenazine.
What special precautions should I follow? Before taking perphenazine (#3.) Tell your doctor if you have or have ever had brain damage, any condition that affects your blood cells, including conditions that affect the production of blood cells by your bone marrow, or liver disease. Your doctor may not want you to take perphenazine."

On 01/31/11 at 11:00 a.m. the DON revealed that a new observation sheet and protocol had been adopted which described how the nursing staff would assess their patients during rounds on the unit. All nursing staff were in-serviced on Saturday, 01/29/11; Sunday, 01/30/11; and Monday, 01/31/11. The document stated:
"In-Service: For all Nursing Staff to attend. New Observation Sheet noting the change in assessment of nursing staff to ensure patients are breathing. For staff to assess patients during the night time checks.
1. Reason for q 15 minute check
a. Patient safely in facility
b. Patient alive and well
2. Importance of communicating with team
a. Understand how to observe sleeping
b. The importance of reporting ALL change to nurse."


Review of RN #1 and LPN #2's personnel records revealed no documented evidence that they had been oriented to APU on hire.

On 01/31/11 at 3:15 p.m. the MHT (#2) who found Patient #1 dead was asked about the incident. The MHT stated that she was obtaining a.m. vital signs when she went into Patient #1's room. She called the patient's name and got no response. She turned the light on and noted the patient's legs were bent, her head was off the side of the bed to the left and side rails were down. MHT #2 stated that the patient looked like she had thrown up. She had mucus in her mouth and nose. The patient was soiled with wetness in front area of her pants and was noted to have on street clothes. The MHT revealed she gave the patient graham crackers at approximately 8:00 p.m. Then at approximately 10:00 p.m. the patient walked to the nurse's station and returned a Bible she had borrowed from the desk. "She appeared fine at that time. I went into her room at 11:00 p.m. or 12:00 a.m. and she was breathing with no distress. At approximately 5:45 a.m. I went into the room to get vital signs and the patient was not breathing. I stepped out in hallway and told nurses she was not breathing. I helped get her out of the bed and on to the floor. CPR was started. I helped with other patients in the dayroom so they would remain calm. I always check to see if patients are breathing on 15 minute checks since the death of (Patient #1). We also started using night lights (flash lights) after her death." The MHT stated that she was in on the debriefing after Patient #1's death.

On 01/31/11 at 3:50 p.m. LPN #2 , who was pulled from the medical/surgical part of the hospital to APU because the two (2) RNs who work the APU called in, was asked about the incident of 01/07/2011 when Patient #1 was found deceased. LPN #2 stated, "I was assigned to check on this patient every 30 minutes. If anything was wrong I would look at the patient every 30 minutes. I was pulled from the medical /surgical unit to work APU because they were short. Usually they work with four MHT's each night. I did not have training for the APU in orientation. I did not have any training in any of the psychiatric units, but I have been pulled a lot to work in the geri-psychiatric unit for three (3) or four (4) months." LPN #2 stated that a lot was going on in APU because two (2) nurses had called in for the 01/06/11 7p.m. to 7a.m. shift. "Last time I saw (Patient #1) it was 2:30 a.m. on 01/07/11. She was sleeping with no distress noted. I went back to doing chart checks. I did not get a report on patients that night. I gave the 9:00 p.m. medications. I gave (Patient #1) Lortab 10 mg. and her regular 9:00 p.m. medications. I gave her Trilafon 2mg. tabs (tablets). I gave four (4) tabs to equal 8 mgs." The LPN was unable to state what class of drug Trilafon was or any possible side effects. She stated that she helped with the Code Blue for Patient #1. "She was cold and looked dead. She was facing the window with her mouth clinched. They put a tube in her nose. I had to go to the supply room for O2. The O2 supply was empty that they had on the floor. The patient was very incontinent of urine and stool and I could smell feces and urine. They were unable to get an IV line. The EMT finally got here. The family was called and the sister came up. The Coroner came up. I know (Patient #1) because she is in the hospital a lot for her sickle cell crisis condition."

On January 31, 2011 at approximately 6:00 p.m. the Coroner was interviewed via the telephone. The Coroner revealed that she felt like Patient #1 had been dead for at least 4-5hours when she arrived. She stated, "The body was very stiff and rigor mortis had already set up. I feel that the patient had not been checked on all night. Her body was soiled with urine and feces. Her face had dried mucous around her mouth. When I got there I told the nurses to leave her body and room like it was until I spoke to the nurses at the nurses' desk. When I returned the staff had cleaned the patient up and boxed all her things. I made a copy of the chart to send to Jackson along with the body for autopsy."

Telephone Interview with RN #1 at 3:35 p.m. on 02/02/11 revealed that she started working at the Behaviorial Health Unit February 2010. When asked about the incident the morning of 01/07/11 she stated, "I came on at 7:00 p.m. I did talk with (Patient #1) in the dayroom at approximately 7:30 p.m. or later. I did not document in detail, however, I did document her behavior. (Patient #1) came to me later complaining of pain. The LPN gave medications at approximately 9:00 p.m. I was present at the briefing that morning after (Patient #1's) death. We talked about the coroner coming in asking who was present at the patient's code. We talked about the equipment not working correctly. I went into her room at approximately 12:00 midnight. I didn't see any concerns. She didn't go to bed until 10:30-11:00 p.m.. I can't remember my last time in the room, around 4:00-5:00 a.m. she was not up having any behavior problems. I did not check respirations. At night we do not go in to rooms, we just make sure they are there. Responsibilities of my duties on the floor are patient safety and auditing charts. I was told in report that this patient was hearing voices and that was the reason for being in the hospital. I might have read that in the ER record. I was unaware of medications." When asked, "Were you aware of the medications (Patient #1) was on? RN #1 replied, "No it was night so I didn't look at the MAR (Medication Administration Record)". RN #1 denied knowing that the patient received blood on 12/30 and 12/31/2010 in the main hospital. The RN stated that she was doing charting on progress notes during the shift. When asked about CPR requirements, RN#1 stated, "I'm not sure if they (the facility) require it, however, in school I had to have it." When asked about in-service requirements the RN stated, "I can't remember except for EKG (Electrocardio gram) training on how to do one. That is usually the reasonability of the MHT as part of the admission process." The RN was asked how patient assignments were decided. She stated, "3-11 Techs (technicians) know who they have when they come in. There is a hand off for techs/MHTs at 11:00 p.m." When asked what the MHT do during their shift she stated, "They go into rooms every 15 minutes and visualize the patient. I am unaware if they assess the patient's respirations. We just have to document where the patient is every 15 minutes. We do get a.m. vital signs."

Based on clinical record review, hospital staff written statements, staff interview, and policy review, the facility failed to ensure the registered nurses and nursing staff supervised, evaluated and monitored the condition of Patient #1 during the night time hours prior to her death on 01/07/2011 and failed to ensure that the patient was properly observed for respirations by the staff and registered nurse during the night time when she was supposedly asleep in her room. The patient was at risk for medication side effects and post blood transfusion side effects. The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the patients' nursing needs would be met.

FINDINGS INCLUDE:

Cross Refer to A-385 for the facility's inability to ensure that the nursing needs of Patient #1 were met. Facility staff failed to monitor and evaluate the patient's condition during the early am hours of 01/07/2011.

Based on record review, staff interview and policy review, the facility failed to ensure that nursing staff supervised and evaluated three (3) out of three (3) patients for respiratory status (Patients #1, #2, and #3).


FINDINGS INCLUDE:

Cross Refer to A385 for the facility's failure to ensure nursing staff supervised and evaluated care for Patient #1, #2 and #3.