The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAPTIST BEAUMONT HOSPITAL 3080 COLLEGE STREET BEAUMONT, TX 77701 Oct. 23, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on records review, interviews, and policy/procedure reviews, the facility failed to follow its own policy and procedures related to suicide precautions.

The facility also failed to ensure suicide assessment, precaution monitoring, and/or nursing asessments were conducted and documented in 4 (#1,#2, #3, and #4) out of 5 (#1,#2,#3, #4, and #5) records reviewed.

This deficient practice created the likelihood of harm to all patients receiving care in the facility and resulted in the death of 1 (#2) of 5 patients reviewed. A patient was able to carry through a suicidal idea due to lack of suicidal assessment and monitoring.
Refer to TAG A0115


It was determined that this deficient practice created an Immediate Jeopardy situation and placed the health and safety of patients in serious jeopardy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews, and policy/procedure reviews the facility failed to follow its own policy and procedures related to suicide precautions. The facility also failed to ensure suicide assessment, precaution monitoring, and/or nursing asessments were conducted and documented in 4(#1,#2, #3, and #4) out of 5 (#1,#2,#3, #4, and #5) charts reviewed. This deficient practice created the likelihood of harm to all patients receiving care in the facility and resulted in the death of 1(#2) of 5 patients reviewed.
Review of the chart revealed Patient #2 was picked up by Emergency Medical Services (EMS) at his home on 10/9/2013 and presented to the emergency room (ER) at 6:10PM.
Review of the ER nurses notes revealed that Patient #2 had consumed 30, 10mg Valium (Antianxiety Medication), at his home. EMS administered 50mg of Charcoal in route to the hospital. Patient #2 was alert and coherent upon arrival to the ER.
Review of the ER Physician documentation on 10/9/2013 at 1829 (6:29PM) physician noted "Patient states he consumed an entire bottle of Diazepam (Valium), 30 pills, onset today. The patient took the pills to clear his mind and make him feel smarter. EMS gave the patient 50mg of charcoal."
Patient #2 was medically cleared in the ER. The ER physicians discharge diagnosis stated, "10/9/2013 19:55 (7:55PM) Admit order for staff #14. Preliminary diagnoses are Drug Overdose Intentional, Suicide Attempt." Patient #2 was discharged to the psychiatric unit on 10/9/2013 at 10:49PM for further evaluation.
On 10/9/2013 at 11:30PM Patient #2 was assessed by a staff #18, a Licensed Professional Counselor (LPC) in the admissions department of the psychiatric unit. Staff #18 documented "Has a history of psychiatric hospitalization s at this facility recently and a history of psychiatric treatment of Anxiety and Depression who is here on an Application to Facility for Emergency Detention which states, He took 28-30, 10mg tabs of valium 10/09/2013, because he wanted to be a better person. Stated the valium makes him feel better. During the screening, patient verbalized the same comment that the Valium made him feel better, think smarter and that was the reason he took it but doubts he took the amount stated."
Review of policy and procedure "Standards of Care: Suicide Precautions" revealed the following:
"The Suicide Risk Assessment Tool is used to identify those patients who may be at risk for suicide. The results of the assessment will determine the potential for the patient harming themselves, and the level of the precautions the patient will receive. The intent is to identify and minimize the possibility of a patient harming themselves when there has been an indication of suicide potential.
b.) The psych admission RN will complete a preliminary Suicide Risk Assessment as part of the intake and screening process.
e.) The Medical Director or a Registered Nurse may initiate a higher level of protective measures for the protection and safety of the patient with notification to the patient's attending physician of the assessed need. Orders for specific precautions will be obtained.
f.) Levels of suicide precautions:
Low risk patients Level I:
-be admitted to the Adult Unit; if appropriate
-attend groups on their own.
-have one hour monitoring for unpredictable behavior.
Moderate risk patients Level II:
-Be admitted to the Acute Unit
-Have 15 minute checks.
Level III high risk patients pose a severe risk for harming or killing him/herself, even in an inpatient setting and will be considered on high risk precautions. These patients will:
-be admitted to the Acute Unit
-have 15 minute checks
-will be restricted to the unit
-1:1 staff monitor within arm's length at all times.
Attachments: Suicide Risk Assessment and No Harm Contract."

Patient #2 was given a Suicide Risk Assessment by staff #18. Review of the "Suicide Risk Assessment Form" had the following eleven categories:
1.) Suicidal Ideation
2.) Suicide Plans
3.) Suicide Attempt
4.) Depressive Thoughts
5.) Orientation
6.) Thought Processes
7.) Affect, Mood, Eye Contact
8.) Stressors
9.) Physical Health
10.) Psychiatric Diagnosis
11.) Available Resources
The patient is evaluated and given a score of 0-15 points per category. The scores are combined from each category and a suicide level is assigned based on the total. The rating scale states, "A Score of 0-89 points: is a Level I with a minimal documented every hour monitoring for unpredictable behavior. A Score of 90-139 points: Level II must be placed in a locked psychiatric unit with a minimum every ten minute checks on Suicide Precautions. Score of 140-165 points: Level III This patient is at severe risk for harming or killing his/herself, even in an inpatient setting. Patient must be placed in a locked psychiatric unit with 1:1 staff monitor within arm's length at all times, and documented every ten minute check on Suicide Precautions. Note: Low risk does not mean that a patient is not capable of committing suicide. Factors or items not included in this assessment tool may influence whether or not a patient may harm or kill themselves. A collaborative multidisciplinary approach to assessment and care must be utilized in determination of a patient's condition."
Patient #2's points added up to 75 which would put him at a level I according to the "Suicide Risk Assessment" scale. Staff #18 further documented patient #2 was having excessive involvement w/: impulsivity, risk taking behavior, depressed mood every day, irritable mood every day, appetite decreased, helplessness, agitation, easily fatigued, difficulty concentrating, disorganized speech, loosening of associations, angry, distractible, bored, wringing hands, and "thought contact: clear suicidal threat as manifested by: having disorganized thoughts that Valium would make him smarter. Recent O.D. on Valium denies homicidal thoughts."
Review of the "No Harm Contract" revealed the following, "I promise not to harm myself/others while in the hospital. If I start to feel as if I want to harm myself/others, I will seek out a staff member (Therapist or Nurse) to talk with." The form has a patient signature line, along with a witness line, and a place for the patient to write comments. Review of patient #2's chart revealed that a "No Harm Contract" was not on the chart.
A physician order was obtained by telephone on 10/10/2013 at 12:30AM to place the patient in observation status. The attending physician, Staff #16, gave an order that "Patient #2 will be a Level II on the Adult Acute Unit, and no medications will be given until he is seen by the physician."
Review of patient #2's nurse's notes on 10/10/13 at 2:37AM revealed Patient #2 was "admitted with Major Depressive Disorder, Height 6' 2", Weight 160lbs." Review of Nurses notes dated 10/10/13 at 2:37AM, under "Assessment to Minimize Restraint and Seclusion Used" revealed the patient said, "Yes" to "risk for self-harm or harm to others", however, nursing notes dated 10/10/2013 at 2:57 revealed staff #20 documented based on a "BH Suicide Assessment" patient #2 was having no thoughts or general thoughts of suicide, no plans for suicide in the last 24/72 hours.
Interview with Staff #22 reported that he had heard someone call for help down the hall. Staff #22 and #21 ran to Patient #2's room and saw patient #2 with a sheet around his neck and staff #26 holding patient #2 up. Staff #22 reported that the facility did not have any cut down scissors. Staff had attempted to cut the sheet with bandage scissors but was unable to cut it. The knot was undone and Patient #2 was laid on the bed. Staff #22 reported he checked his pupils and placed Patient #2 on the floor where CPR was initiated. Code Blue was called overhead. Staff #22 reported that the cart was brought in and Oxygen was applied and the patient was given ventilations with an AMBU Bag. Staff #22 reported that he remembered the AED cycling a couple of times but never advised to shock.
Staff #22 reported that he saw staff #17 and she was keeping notes for the Code Sheet. Staff #22 reported that he did not have any written information on code onset or completion.
Review of nurse's notes for Patient #2 on 10/10/13 revealed the following:
3:01AM- Patient #2 denies suicidal ideation.
4:28AM- Patient #2 resting quietly with eyes closed.
6:45AM Staff #16 was present making rounds.
8:56AM a shift assessment was performed.
9:03AM Patient #2 denies suicidal ideations but he is not interacting and attending group.
1:25PM Patient #2's mother was notified of the patient's transfer to the ER.
1:39PM Staff #16 was notified of the transfer for patient #2 to the ER.
1:40PM Staff #17 documented, "On or about 1:15PM was called to the patient's room by house keeper. Upon entering the patients room this RN and other staff members found patient hanging from the air vent by a sheet. Patient released and placed to the floor. Code Blue called and CPR initiated and AED applied. 911 called for assistance. Staff #16 notified and orders to transport."
Review of Patient #2's chart revealed a "Precautions Flow Sheet." The Precautions Flow Sheet was filled out by the Staff #26 and provided information on suicide level, the location of the patient, and behavior, and interventions. The documentation is in 15 minute intervals.
The Precautions Flow Sheet dated for 10/10/13 revealed:
Patient #2 arrived to the floor at 2:35AM.
Patient #2 was in his room and lying down from 3:00AM to 6:30AM.
Patient #2 was in his room and sitting from 6:45AM-7:00AM.
Patient #2 was in his room and lying down from 7:15AM-10:30AM.
Patient #2 had gone to court at 10:45AM.
Patient #2 was in his room and lying down from 11:00AM to 1:00PM.
Patient #2 was in his room with staff from 1:15PM to 1:30PM. At 1:40PM the MHT documented, "to ER via EMS @ 1340 (1:40PM)." There are no documented conversations between staff members or other patients on this flow sheet.
Review of Patient #2's chart revealed a physician psychiatric evaluation was done but the time and date were illegible. Staff #16 documented "yes" to suicidal ideation, checked the box for suicidal precautions, but did not circle what level of precautions.
An interview with Staff #21 on 10/23/13 revealed that on 10/10/2013 staff #21 was the charge nurse for the day shift, Adult Acute Unit. Staff #21 reported the RN supervision for patients was split between staff #21 and staff #22. Staff #21 reported that Patient #2 was assigned to Staff #22. Staff #26 was assigned as the MHT and the Licensed Vocational Nurse (LVN) administered all meds.
Staff #21 reported that Patient #2 was seen talking to his roommate earlier in the day. Patient #2 was calm and lying down or sitting up conversing in his room. The roommate discharged around mid-morning leaving the patient #2 alone in his room. Staff #21 reported that patient #2 was anxious about the court hearing that morning. Patient #2 was not sure what was going to happen. Staff #21 reported that she explained to patient #2 what was going to happen and that he had nothing to be worried about. There was no documentation in the nurse's notes on the patient's anxiety before court, one to one conversation, nursing intervention, or when patient #2 left the floor and returned. There is no documentation in the nurse's notes after 9:03AM until 1:35PM.
Staff #21 reported Patient #2 had denied he was suicidal or homicidal. Staff #21 stated, "I was shocked that he did this. I have been doing this for a while now and you just know when someone needs that extra attention. In hindsight I guess I could have put him with a 1:1 but I didn't see where that was something I needed to do. He was on 15 minute checks. He was calm, pleasant, and smiling."
Interview with Staff #22 reported Patient #2 was in his room talking off and on with his roommate. Staff #22 reported that he performed the morning assessment on Patient #2 the morning of the incident on 10/10/13. Patient #2 was calm, quiet, and denied suicidal or homicidal thoughts.
Interview with Staff #26 on 10/23/2013 revealed Patient #2 was in the patient room with a roommate that morning and was conversing with the roommate. Staff #26 reported that the roommate was discharged mid-morning and that Patient #2 was in his room alone. Staff #26 reported that the patient's door was left slightly open so the staff could look inside to do visual checks every 15 minutes. This would prevent the staff from waking or disturbing the patients. Staff #26 reported that he checked on Patient #2 every 15 minutes and he was just lying down or sitting in the bed. Staff #26 reported that the patient was just lying there and looking around room. Staff #26 reported that he would talk to Patient #2 and he "seemed alright." Staff #26 reported that he saw no difference in Patient #2's behavior before he went to court and when he returned. Review of the nurse's notes and the "Precautions Flow Sheet" revealed no documentation of conversations with Staff #26 and Patient #2.
Review of the chart revealed a progress note written by Staff #13 on 10/10/13 at 10:30AM. Staff #13 documented, "Probable cause hearing today pt. present. Judge Defense attorney and District Attorney, mother and grandparents present. Based on testimony presented it was determined that evidence did exist for in pt. psych ('illegible word') not to exceed 14. P.C. expires 10/22/13." There was no further documentation on patient #2's behavior, if anxiety was resolved or increased, conversation of staff #13's explanation on court hearing, and if patient had a full understanding.
Review of patient #4's chart revealed this was a [AGE] year old female admitted to the Adult Acute Unit with Schizophrenia and Post Traumatic Stress Disorder. Patient #4 had attempted suicide by drinking bleach, voiced a desire to die, and threatened to kill others upon admission. Patient #4 was placed on Level II precautions with aggression but neither Suicide Precautions nor a 1:1 intervention was ordered.
Review of the Patient #4's chart revealed on 10/17/2013 at 9:47PM a Restraint Order Sheet was completed to perform a personal hold in order to remove a plastic fork from the patient. Patient #4 had gone to her room and broken a plastic fork attempting to cut herself. Staff requested Patient #4 to release the plastic fork and she refused causing the staff to perform a personal hold to obtain the fork. Patient #4 was violent with threats to staff and others. Patient #4 was placed in an observation room with 15 minute checks. No orders were written for a 1:1.
Review of Patient #4's Nurses Notes dated 10/18/2013 at 8:00AM states, "Staff #14 here making rounds, visiting with patient. 8:05AM Patient is threatening to hurt another patient, stated 'I'm going to stab her in her eye." Patient is being aggressive and hostile at this time, redirecting to the day area to sit down and remain calm. Will continue to monitor. 8:30AM Patient aggressive, angry and hostile, stated 'I don't want to be one to one, why the hell he made me one to one?' Patient kicked the examination room and broke the lock on the door and broke it. Patient redirected to quiet area. Remains one to one level 2 per doctor's order. Will continue to monitor."
An order was written on 10/19/2013 at 2:45PM to discontinue the 1:1.
Review of the Precaution Flow Sheet for 10/18/2013- 10/19/2013 revealed there was no documentation that Patient #4 was on a one to one intervention for the following dates and times;
10/18/2013- 11:15- 12:00PM, 12:45PM-1:45PM, 10:15PM-11:45PM.
10/19/2013- 12:45AM-6:15AM, 6:45AM-2:00PM.
Review of Patient #3 ER Physician Note revealed that Patient #3 is a [AGE] year old male, walked into the ER with complaints of "Psych Problems" , was admitted to the facility on [DATE] for Bipolar Disorder, Borderline Intellectual Functioning, Seizures, Homicidal and Suicidal Ideations with no plan. Patient #3 is involuntary and had an Emergency Detention Warrant from Beaumont Police Department.
Review of Patient #3 ER Physician Note on 10/9/2013 at 4:28PM states, "The patient presents to the emergency department with homicidal ideation, suicidal ideation, but the patient has no formulated plan. The patient has experienced similar episodes in the past, several times. Disposition: 10/9/2013 at 6:53PM Admit order for Staff #14. Preliminary diagnosis is Depression Major."
Review of Patient #3 ER Nurses Note on 10/9/2013 at 6:31PM reveals Staff #18 performed a Suicide Risk Assessment and screening. Staff #18 reported that the Patient #3 was there alone during the interview and the history was obtained from an Emergency Detention Warrant. Patient #3 has a history of prior suicide attempts and stated, " He doesn't want to be on this earth again." Suicide Risk Assessment was incomplete and no score with recommendations were given. There was not a "No Harm Contract" in the chart. Patient #3 was placed on, "every 15 minute safety checks."
Review of the physician orders revealed Patient #3 was placed on Fall, Seizure, and Suicide Precautions, Level II, on 10/09/13 at 4:05PM.
Review of the Precaution Flow Sheet for 10/11/2013 revealed the following;
4:15AM and 6:00AM no staff initials present.
7:15AM is blank. No documentation of 15 minute safety check.
7:45AM-8:15AM was blank. No documentation of 15 minute safety check.
8:45AM-9:15AM was blank. No documentation of 15 minute safety check.
9:45AM-10:15AM was blank. No documentation of 15 minute safety check.
10:45AM- 11:15AM was blank. No documentation of 15 minute safety check.
11:45AM-12:15PM was blank. No documentation of 15 minute safety check.
12:45PM-1:15PM was blank. No documentation of 15 minute safety check.
1:45PM-2:15PM was blank. No documentation of 15 minute safety check.
7:15-7:30PM had no information of location or behavior but had staff initials.




Based on document review and interview the facility failed to evaluate and assess food allergies in 1 of 1 patients reviewed, creating an unsafe setting for care.


On 10/15/2013 a written complaint was received by the mother, who was the primary care giver, for patient (pt) #1. She alleges her son, pt #1 had a severe food allergy and she was not able to get any nursing staff to take her information or return her calls regarding her sons' food allergy.


On 10/22/2013 at 10:00 AM in the conference room the medical record (MR) of pt #1 was reviewed and revealed the following:. The Emergency Department physician intake notes documented, pt #1 was a [AGE] year old male patient who was brought to the Emergency Department (ED) under a Emergency Detention Warrant (EDW). Pt #1 was remanded from his high school. The ED physician documented the patient's sister reported he had a well established history of Autism.


The initial Psychiatric/History and Physical noted pt #1 was allergic to peanuts. No further information was documented by the Psychiatrist as to severity of the allergic reaction or the symptoms observed in the patient from the peanut sensitivity. This information was only found on the initial history and physical documentation by the Psychiatrist.


Further review of the admission nursing assessment revealed no documented nutritional assessment. The nursing documentation for nutritional services consisted of the following two phrases; "Dietary: Food likes, no details. Food Dislikes, no details". No other assessment of nutritional or dietary evaluation was found in the MR documentation.

On 10/24/2013 in the conference room at 9:30 AM staff #5 was interviewed regarding the nutritional evaluations performed by hospital nursing staff. Staff #5 revealed that the nutritional evaluation for psychiatric nursing services should be the same as the acute inpatient nursing evaluation. It was explained to staff #5 that no nutritional evaluation was identified within the MR of pt #1. Further it was explained that with out a nutritional evaluation no dietary consult was generated. And with out a dietary consult the psychiatric nursing staff took on all responsibility for meeting the nutritional need of pt #1 as well as potential life threatening problems pt #1 might have exhibited, related to his peanut allergy. The only allergy listed by nursing for pt #1 was a Rocephin drug allergy.


It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had the likelihood to affect all patients admitted to the facility.
VIOLATION: NURSING SERVICES Tag No: A0385
Based upon observations, records review, and interviews, the facility failed to follow its own staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 5 of 5 patient care units.


The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision.


This practice created the potential for harm for all patients due to lack of safe patient supervision.


Refer to Tag A-392.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based upon observations, records review, and interviews, the facility failed to follow its own staffing plan and staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 5 of 5 patient care units. The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision. This deficient practice created the likelihood of harm to all patients due to lack of safe patient supervision.


Review of the facility policy titled "Acuity Classification/Assignment of Patients" revealed the following information:

Process: Patient care is determined based on the registered nurses assessment of the patient. Using the nursing process, the patient's needs will be identified. Individual nursing personal will be assigned to patient's based on consideration of the patient's acuity, patient's needs, and the individual personnel's ability and experience required to provide care.

Patient acuity identification is an ongoing process that determines the individual patient care requirements. Patient acuity is reflected as low acuity (Category 1), expected acuity (Category 2), or high acuity (Category 3). The acuity criterion is established for each unit and reflects staff and management collaboration to establish. The acuity criteria determination is a dynamic process changing as patient population and technology change.

The skill mix of nursing care may consist of a combination of disciplines including RN, LVN, Techs, Clerical, etc. The skill mix is utilized with productive hours per patient/procedure/visit to determine base staffing productivity standards. The productivity standards are based on an acute category 2( expected acuity for that unit/department population). Staffing is adjusted based on the acuity levels assigned to patients. At a minimum each unit will have one RN per shift.

Procedure: 4.) The staffing is reviewed and adjusted, as needed at least every shift by the charge nurses, unit manager and or unit director. The shift charge nurse will communicate with the nursing director. Adjustments are made for the acuity of the patient and unusual occurrences, i.e., excessive number of call ins, patients requiring one to one care and aggressive/violent patients. The skill mix and productivity standards are a guide and at any, a time the unit director, in consultation with the nurse in charge, may adjust the staffing based on the circumstances of the unit at that time."


Further review of the policy "Acuity Classification/Assignment of Patients" revealed there were no guidelines for determining the acuity of the psychiatric patient and how adjustments to staffing would be determined based upon the acuity of the patients. The plan also had no provisions for additional staffing when patients required 1:1 or "line of sight" monitoring.


Review of the "Staffing Grid" revealed a core staffing level that determined the number of RN's(Registered Nurse), LVNs(Licensed Vocational Nurse, and MHTs(Mental Health Technician) needed on each unit based upon the number of patients on each unit.


Review of the staffing schedule and grid for the psychiatric unit dated 10/1/2013-10/22/2013 revealed the following:

The Adult Unit revealed 17 of 66 shifts were staffed inadequately and 9 of those 17 shifts were short one licensed staff.

The Acute Unit revealed 23 of 66 shifts were staffed inadequately and 6 of 23 shifts were short one licensed staff.

The Adolescent Unit revealed 29 of 66 shifts were staffed inadequately and 7 of 23 shifts were short one licensed staff.

The Senior Care Unit revealed 23 of 66 shifts were staffed inadequately and 4 of 23 shifts were short one licensed staff.


The Admissions Unit did not have a grid so the determination was based on the Acute Unit grid. The Admissions Unit revealed 14 of 66 shifts were staffed inadequately and 4 of 14 shifts were short one licensed staff.


Interview with staff #3 confirmed the grids given to the surveyors were used to staff the psychiatric units. Staff #3 confirmed that there was not a grid used to staff the Admissions Unit. Staff #3 confirmed that the administration was aware the units were under staffed. Staff #3 reported that it had been difficult to get nurses for the psychiatric unit.


Interview with staff #10 confirmed that the facility has been short staffed and the administration personnel were aware for several months. Staff #10 stated, "It's hard to staff this place when you don't have a pool of people to draw from. I do the best I can but there are many times I cannot staff this place no matter how hard I try. They will continue to admit patients even when I can't staff it."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observations, interviews, and record reviews, the facility failed to follow its own policy and procedures to provide patient assessment in 1 (#2) out of 3 (#1, 2, and 3) charts reviewed. The facility failed to provide ongoing assessment that included the assessing of patient care needs, patient's health status, and patient's response to resuscitation efforts, and treatment in accordance with accepted standards of nursing practice. Nursing also failed to document the Cardio Pulmonary Resuscitation (CPR) process and results.
Review of the chart revealed Patient #2 was picked up by Emergency Medical Services (EMS) at his home on 10/9/2013, and presented to the emergency room (ER) at 6:10PM.
Review of the ER nurses notes revealed that Patient #2 had consumed 30, 10mg Valium (Sedative), at his home. EMS administered 50mg of Charcoal in route to the hospital. Patient #2 was alert and coherent upon arrival to the ER.
Review of the ER Physician documentation on 10/9/2013, at 1829 (6:29PM), physician noted "Patient states he consumed an entire bottle of Diazepam (Valium), 30 pills, onset today. The patient took the pills to clear his mind and make him feel smarter. EMS gave the patient 50mg of charcoal."
Patient #2 was medically cleared in the ER. The ER physicians discharge diagnosis stated, "10/9/2013, 19:55 (7:55PM), Admit order for staff #14. Preliminary diagnoses are Drug Overdose Intentional, Suicide Attempt." Patient #2 was discharged to the psychiatric unit on 10/9/2013, at 10:49PM, for further evaluation.
On 10/9/2013, at 11:30PM, Patient #2 was assessed by staff #18, a Licensed Professional Counselor (LPC) in the admissions department of the psychiatric unit. Staff #18 documented "Has a history of psychiatric hospitalization s at this facility recently and a history of psychiatric treatment of Anxiety and Depression who is here on an Application to Facility for Emergency Detention which states, He took 28-30, 10mg tabs of valium 10/09/2013, because he wanted to be a better person. Stated the valium makes him feel better. During the screening patient verbalized the same comment that the Valium made him feel better, think smarter and that was the reason he took it but doubts he took the amount stated."

Review of nurse's notes for Patient #2 on 10/10/13, revealed the following:
3:01AM- Patient #2 denies suicidal ideation.
4:28AM- Patient #2 resting quietly with eyes closed.
6:45AM Staff #16 was present making rounds.
8:56AM a shift assessment was performed.
9:03AM Patient #2 denies suicidal ideations but he is not interacting and attending group.
1:25PM Patient #2 ' s mother was notified of the patient ' s transfer to the ER.
1:39PM Staff #16 was notified of the transfer for patient #2 to the ER.
1:40PM Staff #17 documented, "On or about 1:15PM was called to the patient's room by housekeeper. Upon entering the patients room this RN and other staff members found patient hanging from the air vent by a sheet. Patient released and placed to the floor. Code Blue called and CPR initiated and AED applied. 911 called for assistance. Staff #16 notified and orders to transport."

Review of the patients nurses notes for 10/ 10/13, revealed the nurses failed to document:
- Condition of the patient when removed from the ligature.
-The first rhythm that required compressions, response to stimuli, or reactive or non- reactive pupils.
- What type of respiratory compromise and/or deterioration the patient was currently experiencing.
-What type of airway interventions or if Oxygen was administered.
- The AED use, action, and results.
-When the resuscitation event ended and what time the patient left the facility.

Review of the policy and procedure "Emergency Medical Care" for behavioral health states, "In the event that a patient, prospective patient or individual at the Behavioral Health Center experiences a medical emergency or a cardiopulmonary crisis requiring resuscitative efforts, a Code will be initiated with immediate notification of EMS for transport to the Emergency Department. Staff Responsibilities: The RN will be responsible for assuring all documentation is complete on review sheet, code flow sheet and progress notes."

Interview with Staff #22 reported that he had heard someone call for help down the hall. Staff #22 and #21 ran to Patient #2's room and saw patient #2 with a sheet around his neck and staff #26 holding patient #2 up. Staff #22 reported that the facility did not have any cut down scissors. Staff had attempted to cut the sheet with bandage scissors but was unable to cut it. The knot was undone and Patient #2 was laid on the bed. Staff #22 reported he checked his pupils and placed Patient #2 on the floor where CPR was initiated. Code Blue was called overhead. Staff #22 reported that the cart was brought in and Oxygen was applied and the patient was given ventilations with an AMBU Bag. Staff #22 reported that he remembered the AED cycling a couple of times but never advised to shock.

Staff #22 reported that he saw staff #17 and she was keeping notes for the Code Sheet. Staff #22 reported that he did not have any written information on code onset or completion.

Review of the policy and procedure titled "Code Blue", Section titled "Cardiopulmonary Arrest Occurring Outside Of The main Hospital for Beaumont Hospital Only (Behavioral Health Center, Cancer Institute, Wound Care Center)" revealed the following:
In addition to BLS (Basic Life Support), advanced life support is available in all patient care settings except for off site primary care facilities. The acuity level of patients on the off-site primary care clinics does not warrant consistent availability of advanced life support. Should such a need arise, BLS support will be provided, and the Emergency Medical System, (EMS) will be activated. Responding EMS will then provide advanced life support.
-Verbally call for assistance or send another person for assistance.
-Call 911 for patient transport by EMS to ER.
-Initiate Basic Life Support under the current guidelines set by the American Heart Association, if the patient's condition warrants.
-personnel will bring the following supplies to Code Blue events: AED, transportable Oxygen and an emergency toolbox or bag.
-One RN team member and the RN/LVN responsible for the patient will remain with the patient until the transport to the ED by EMS.

According to this policy, the inpatient behavioral health unit of the hospital is categorized as an off-site primary care clinic that does not warrant availability of advanced life support.

Review of the "Code Blue Flow Sheet" dated 10/10/2013, had a top section that addresses general first intervention information. Patient #2's weight and height was left blank.
-The second section "Airway/Ventilation" revealed that Agonal breaths were present on onset of the first assisted ventilation at 1317 (1:17PM), and Ventilation Type: was "bag". On the section that addresses Intubation and intubation drugs, a line is drawn through and states, "per EMS".
-In the third section the "First Rhythm Requiring Compressions" is blank.
- The middle section addresses Vital signs, Bolus Dose, and Drip's. Under "Vital Signs" column, at times 13:17 and 13:18, there were no vital signs documented but documentation of "AED No shock advised". There was no further time of compressions documented after 13:18. It is documented on the Code Flow Sheet that EMS arrived at 13:20. There is no documentation of heart rhythm, AED readings, or strips.

The last section of the "Code Blue Flow Sheet" revealed the resuscitation ended at 1340, Patient #2 was alive, reason resuscitation ended was left blank, no EKG strips on chart, patient was transferred to ER, and physician and family notified.

Review of the "Code Blue Flow Sheet" had two signatures staff #17 and staff #21. There was no other documentation in Patient #2's chart listing staff members involved in the Code Blue process.

Interview on 10/23/13, with Staff #17 revealed she was on duty when the Code Blue was called on 10/10/13. Staff #17 reported that she was on the bottom floor. When staff #17 heard the Code Blue announcement she headed up to the Adult Acute Unit. Staff #17 reported that when she entered Patient #2's room CPR was already in progress. Staff #17 reported that she started to write down some times and events that were being performed during the CPR process.

Staff #17 reported that she was advised over the phone by Staff #9 and #3 to fill out a Code Blue Sheet. Staff #17 reported that she only filled out the top portion of the "Code Blue Flow Sheet" and signed the second page. Staff #17 was shown the Code Blue Flow Sheet dated 10/10/13. Staff #17 confirmed that her documentation was on the top only and was not sure whose writing was on the remaining part of the form.

Interview with staff #9 on 10/24/13, revealed that she had filled out the incomplete portions of the code sheet for Patient #2. Staff #9 was not involved with the code and was not working in the facility on 10/10/13. Staff #9 reported that she did not complete the code sheet until 10/14/2013, four days after the event. Staff #9 did not sign the form stating she had completed the form.

Staff #9 wrote a statement that states, "On Monday October 14, 2013, I scribed the Code Sheet to ensure completion. I obtained the information for the individuals present, Staff #21 and Staff #25. The portions completed include: Airway/Ventilation, Vital Signs, Bolus Drips, Drips, and the portions below. The documented information was reviewed by staff #21 for accuracy prior to submittal into the medical record."

Interview with Staff #21 on 10/23/13, revealed that she was involved with the Code. Staff #21 reported that she did not know what the times were during the code because she was giving compressions and active with the patient care of the Code. Staff #21 reported that staff #17 had all the data for the Code Flow Sheet. Staff #17 had filled out the top part of the form and had Staff #21 sign the back of the form. Staff #21 reported that she was aware that staff #9 was filling out the rest of the Code Sheet four days later.