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.

EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY 40511 Sept. 30, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient's rights and prevent neglect of patients for one (1) of ten (10) sampled patients (Patient #1). Patient #1 was admitted to the facility on [DATE] at 9:30 AM with multiple diagnoses which included Hypertension, Psychotic Disorder, Not otherwise specified, and Gastroesophageal Reflux Disease. Staff interview revealed Patient #1 conversed with staff and other patients on 09/21/13 and 09/22/13 and ambulated without assistance about the unit. On 09/22/13 between 9:45 PM and 10:00 PM, Registered Nurse (RN) #2 went to Patient #1's room to administer the patient's medications and was unable to awaken the patient. Per interview, two (2) other patients were in Patient's #1's room at that time, and informed her Patient #1 was "not right ". RN #1, the Charge Nurse, was informed and both RN #1 and RN #2 attempted shaking Patient #1 awake; however the patient did not respond. Interview revealed RN #1 and RN #2 thought Patient #1 was "playing possum". Record review revealed no documented evidence the patient was assessed. Sometime before 11:30 PM, Mental Health Associate (MHA) #1 checked on Patient #1 and the patient was "having trouble breathing". Patient #1 "appeared" to have sleep apnea because he/she stopped breathing for seconds, so MHA #1 shook him/her and Patient #1 took a "deep breath". MHA #1 stated she reported this information to RN #2; however, interview and record review revealed no evidence Patient #1 was assessed for a change in condition. On 09/23/13 around 3:15 AM, MHA #1 found Patient #1 not breathing. Staff interview revealed RN #4 and RN #5 performed sternal rubs; however, this was unsuccessful. Interview and record review revealed the physician was contacted; cardiopulmonary resuscitation (CPR) was initiated; a Code Blue was called; and, a call was made to 911. Patient #1 was transported to a hospital ER where he/she was pronounced deceased at 3:58 AM.

The failure of the facility to protect and promote patients' rights and prevent neglect of patients placed patients at risk for injury, harm, impairment or death. The facility was notified on 09/30/13 that Immediate Jeopardy was determined to exist. The Immediate Jeopardy was not abated prior to exit on 09/30/13. (Refer to A0145)
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of facility policies and procedures, it was determined the facility failed to protect and promote patient's rights and prevent neglect of patients for one (1) of ten (10) sampled patients (Patient #1).

The facility failed to ensure information regarding Patient #1's change in condition information was passed along to the next shift; failed to notify the Physician when Patient #1 experienced the change in condition; failed to ensure cardiopulmonary resuscitation (CPR) was immediately initiated in a patient without a pulse and respirations; and failed to immediately call a code when Patient #1 was found without a pulse or respirations.

The findings include:

Review of the facility policy, "Assessment and Documentation, Section 3, I. Change in Condition" dated 10/12, revealed the facility recognized and responded to changes in patient's condition. Review revealed an early response to changes in a patient's condition by a specially trained individual may reduce cardiopulmonary arrests and patient mortality. All patients were to be assessed every shift for a change in condition and the Physician was to be notified immediately to significant changes in the patient's condition within the past forty-eight (48) hours. Review of the same policy, at Section 3, C., revealed licensed staff were to take clinically appropriate action related to abnormal findings in vital signs (V/S) and recheck the V/S within two (2) hours to ensure that actions taken had successfully addressed the abnormal findings. Review revealed if upon recheck the V/S remained abnormal the Physician/APRN (Advanced Practice Registered Nurse) was to be notified.

Review of the facility's, "Code Blue" protocol revealed that the individual finding the emergency was to call the code, secure emergency equipment to the site of the emergency and initiate cardiopulmonary resuscitation if indicated.

Record review revealed Patient #1 had an admission date of [DATE] and diagnoses which included Psychotic Disorder, Not Otherwise Specified (NOS), Hypertension and Gastroesophageal Reflux Disease. Review of Patient #1's vital signs prior to being admitted to his/her unit at 9:30 AM, revealed his/her pulse to be 112 beats per minute (bpm); however, there was no documented evidence of a recheck of Patient #1's pulse two (2) hours later as indicated in facility policy. Review of the Registered Nurse (RN) Shift Assessment forms and the Vital Signs, Weight, and Height Record form revealed Patient #1's pulse on admission at 9:30 AM to his/her unit was 125 bpm sitting and 129 bpm standing; however, there was no documented evidence of a recheck of Patient #1's pulse two (2) hours later as indicated in facility policy. Continued review of these documents revealed the following: on 09/22/13 at 6:00 AM Patient #1's pulse was noted to be 102 bpm sitting and 112 bpm standing; however, there was no documented evidence of a recheck of Patient #1's pulse two (2) hours later as indicated in facility policy. At 4:00 PM Patient #1's pulse was documented as 101 bpm sitting and 105 bpm standing; however, there was no documented evidence of a recheck of Patient #1's pulse two (2) hours later as indicated in facility policy. Further record review revealed the Physician had ordered every fifteen (15) minute observation checks of Patient #1.

Interview, on 09/25/13 at 2:40 PM, with Registered Nurse (RN) #6 revealed she admitted Patient #1 to the unit on 09/21/13 at 9:30 AM. RN #6 indicated at the time of admission Patient #1 had no complaints of shortness of breath, dizziness, no distress. She stated Patient #1's vital signs (V/S) were taken and his/her pulse was high; however, the pulse was not rechecked two (2) hours later as per facility policy. She stated the Physician was not notified of Patient #1's increased pulse at the time of admission.

Interview, on 09/30/13 at 2:31 PM, with Physician #1 revealed he had been on call until 7:00 PM on 09/22/13. Physician #1 stated staff had not informed him of Patient #1's increased pulse during the time he was working. He stated if nursing staff had called him, he would have went and "checked" on the patient.

Interviews, on 09/25/13 and 09/26/13 at various times with Mental Health Associates (MHAs) #2, #3, #4, #5, #6 and #7 and on 09/30/13 with MHAs #8, and #10 revealed they all had observed Patient #1 conversing with staff and other residents and ambulating about the unit.

Interview, on 09/25/13 at 6:03 PM, with RN #2, who was the evening shift medication nurse on 09/22/13, revealed she did not normally work Patient #1's unit. She stated at approximately 9:00 PM on 09/22/13, Patient #1 came to her requesting his/her 9:00 PM medications. She indicated she told Patient #1 she had already given him/her these medications. However, at approximately 9:45 PM, she realized she had been mistaken and had not administered Patient #1's 9:00 PM medications. She stated she got the medications together and took them to Patient #1's room where she found the patient with his/her eyes closed. RN #2 stated she shook Patient #1 and he/she opened and closed his/her eyes. She stated she then poured a couple of drops in the patient's mouth as this sometimes awakened a patient. According to RN #2, Patient #1 opened and closed his/her eyes again and coughed. The RN stated two (2) other patients came into the room while she was there and told her Patient #1 was "not right ". RN #2 stated she then went and "got" RN #1, the Charge Nurse, who was the only other nurse working the unit with her.

Interview, on 09/25/13 at 3:35 PM, with RN #1, who was the Charge Nurse on 09/22/13 on the evening shift, revealed she went to Patient #1's room after two (2) other patients had come to her and "were in an uproar" because Patient #1 was not responding to them. RN #1 indicated she observed Patient #1 with his/her eyes closed. She stated she took Patient #1's vital signs (V/S) which were within normal limits. According to RN #1, she thought she remembered Patient #1's pulse being 101 bpm; however stated she could not remember the blood pressure reading. The RN stated she felt there was nothing to be "alarmed" about. She stated RN #2 was also present in the room at this time and they attempted shaking Patient #1 awake; however, were unsuccessful in their attempts. RN #2 stated Patient #1 did not respond at all. She stated both she and RN #2 thought Patient #1 was "playing possum". RN #1 stated she did not document her assessment or the V/S as there was nothing to be "alarmed" about.

Interview, on 09/26/13 at 10:35 AM, with Patient #2 revealed at approximately 9:30 PM on 09/22/13, he/she heard RN #2, the medication nurse, "yelling" at Patient #1 over and over to wake up. Patient #2 indicated he/she went to Patient #1's room and saw the patient "unconscious with his/her "eyes rolling in" his/her head. The Patient stated RN #2 was not successful in her attempts to awaken Patient #1. He/She stated he/she told RN #2 the "rescue squad" needed to be called. Patient #2 stated he/she observed RN #2 pour Patient #1's medications in his/her mouth and then pour water in the patient's mouth. This Patient stated Patient #1 "started strangling" and the nurse walked out of the room. Patient #2 stated he/she attempted to roll Patient #1 on his/her side by himself; however, was unable to do so. This Patient indicated he/she left Patient #1's room to look for assistance. Patient #2 found Patient #3 and requested that he/she assist with turning Patient #1 on his/her side. He/She stated they went to Patient #1's room and positioned him/her on the side where he/she's "airway was clear enough to breathe" after that. Patient #2 stated he/she told the nurses Patient #1 needed to be sent out; however, they did not do so.

Interview, on 09/26/13 at 4:07 PM, with Patient #3 revealed on 09/22/13 around 10:00 to 11:00 PM, Patient #2 had come to him/her and asked for assistance with turning Patient #1 on his/her side. Patient #3 stated when they went to Patient #1's room the patient was choking. Patient #3 stated Patient #2 had told him/her the medication nurse (RN #2) had poured water in Patient #1's mouth causing him/her to choke. Patient #3 stated he/she and Patient #2 successfully turned Patient #1 to his/her side.

Interview, on 09/26/13 at 9:33 AM, with Mental Health Associate (MHA) #1 revealed sometime before 11:30 PM on 09/22/13, she checked on Patient #1 and observed that he/she was having difficulty breathing. She stated she thought Patient #1 had sleep apnea as he stopped breathing for seconds. According to MHA #1 when she shook Patient #1 he/she took a "deep breath". MHA #1 stated she reported this information immediately to Registered Nurse (RN) #2 who was passing medications that night. However, record review revealed no documented evidence of an assessment having been performed by RN #2.

Interview, on 09/30/13 at 2:22 PM, with Physician #2 revealed at 7:00 PM on 09/22/13 he was working at the facility. According to Physician #2, no one had notified him of staff not being able to awaken Patient #1. He indicated he should have been notified of this information so he could come and examine the patient. Additionally, he stated he had not been informed RN #2 had poured water in Patient #1's mouth. He again indicated he would have expected to have been notified of this information.

Interview, on 09/30/13 at 5:35 PM, with the Senior Nurse Administrator (SNA) revealed his expectation was for staff to follow the facility's policies and procedures. He indicated no one had made him aware of RN #2 pouring water in Patient #1's mouth. He stated that was something that was not condoned or taught at the facility. According to the SNA, if Patient #1 experienced a change of condition on 09/22/13 on evening shift, the Physician should have been notified. Additionally, he stated information regarding the change of condition should have been reported to the oncoming shift to ensure follow up monitoring of the change in condition. The SNA stated observation checks should have been performed as ordered or indicated by the privilege level on 09/22/13.

Record review revealed Patient #1 experienced a headache on 09/21/13 at 7:40 PM and again on 09/22/13 at 12:00 AM. Tylenol was administered and documented to have been effective.

Continued record review revealed observation checks were performed every fifteen (15) minutes and staff noted Patient #1 to be sleeping. Review of the Patient Supervision Record, on which observation checks were documented, revealed no documented evidence observation checks were performed a 9:00 PM, 9:15 PM, and 9:30 PM on 09/22/13.

Continued interview, on 09/26/13 at 9:33 AM, with MHA #1 revealed on 09/23/13 she had performed the 3:00 AM observation checks. She indicated however, she did not start them until approximately 3:05 AM to 3:07 AM. According to MHA #1, she was doing her observation check of Patient #1 approximately five (5) to ten (10) minutes after starting the observation checks. She stated when she got to Patient #1's room he/she was not snoring which had been the case prior to this observation. MHA #1 stated she had shone her flashlight on Patient #1 and he/she was not breathing. The MHA indicated she shook Patient #1; however, he/she did not respond. MHA #1 stated she left Patient #1's room and went immediately to the nurse's station where she informed the nurses of her findings in Patient #1's room. She stated she thought RN #5 got up to go check on Patient #1 while she sat at the nurse's station. MHA #1 stated RN #5 returned to the nurse's station and told her to call a "code blue", which she stated she did. She stated when she had performed her observation check of Patient #1 she could tell "something wasn't right". She stated Patient #1's extremities were cold, his/her chest was "somewhat" warm, and his/her eyes were unresponsive to light.

Interview, on 09/30/13 at 3:15 PM, RN #5, who MHA #1 indicated she had asked to check on Patient #1, revealed she had not been informed in report on 09/22/13 of a change in Patient #1's condition. According to the RN, staff had performed the observation checks and observed Patient #1 breathing, snoring. She stated sometime after 3:00 AM, MHA #1 had come to the nurse's station and reported Patient #1 was not breathing. The RN stated RN #4, who was also at the nurse's station went to Patient 1's room with MHA #1. RN #5 stated MHA #1 returned to the nurse's station and stated RN #4 had requested that she come to Patient #1's room. She stated she went to Patient #1's room where she observed RN #4 performing sternal rubs (painful stimulus to attempt to get a patient to respond) which according to RN #4 had not been effective on Patient #1. RN #5 stated she also attempted the sternal rubs with no response. The RN stated the patient's eyes were "rolled back in" his/her head. RN #5 stated she knew they needed help quick. She stated she ran to the nurse's station and told MHA #1 to call a "code blue" and she went to get the emergency cart. After obtaining the emergency cart, she stated she could tell MHA #1 was having trouble getting the "code blue" to go through for announcement. The RN indicated she was going to go to the medication room to attempt to get the "code blue" call to go through. She stated at that time, she heard the announcement and returned to Patient #1's room with the emergency cart. RN #5 stated numerous staff arrived from other units to assist with the code. According to the RN, Physician #2 also responded to the "code blue". RN #5 reported she had MHA #1 call 911.

Interview, on 09/25/13 at 4:15 PM, with RN #4 revealed on 09/22/13 during report she had not received information regarding staff not being able to awaken Patient #1 on the evening shift. The RN stated sometime during the 3:00 AM observation checks MHA #1 came to the nurse's station and stated she couldn't get Patient #1 up. According to RN #4 the MHA asked her to check on Patient #1, so she did so. She stated she shook Patient #1's arm; however, Patient #1 did not respond to this. She indicated she requested MHA #1 go get RN #5 and have her come to Patient #1's room. RN #4 stated RN #5 came to the room while she was performing sternal rubs (painful stimulus used to elicit a response in an unresponsive patient). She indicated RN #5 also attempted sternal rubs with no patient response. The RN stated she went and called the Shift Supervisor (RN #3) and the Physician; however, did not call a "code blue" as indicated in facility policy. She stated she should have done this. Additionally, RN #4 indicated cardiopulmonary resuscitation (CPR) was not initiated until RN #3, the Shift Supervisor had come to the room and told the nurses to start CPR. RN #4 stated code blue was called after RN #3 arrived in Patient #1's room. In addition, she stated 911 was called and responded.

Interview, on 09/30/13 at 4:00 PM, with RN #3, who was the Shift Supervisor on 09/22/13 on the night shift, revealed she had not received any information related to a change in Patient #1's condition during report. She stated she had just been on Patient #1's unit prior to getting called back to assess Patient #1. RN #3 stated she received a call on her facility assigned cell phone from RN #4. She indicated RN #4 "screamed" at her to come to the unit as they needed help right away. The RN stated she started to run to Patient #1's unit, went to Patient #1's room where she found the patient without a pulse. She stated she "screamed" for the nurses to start CPR, and she started performing mouth-to-mouth respirations on Patient #1 and RN #4 started chest compressions. She stated the patient's body temperature was cool. According to RN #3, if she had been the one to find Patient #1 without respirations or a pulse, she would have immediately called a "code blue". The RN indicated Physician #2 was present when the code was called and he took over the breathing for her. She stated staff continued CPR efforts until Emergency Medical Services (EMS) arrived and took over Patient #1's care.

Interview, on 09/26/13 at 4:30 PM, with the EMS Officer in Charge revealed when emergency personnel arrived at the facility, Patient #1's extremities were cool; his/her "core" was still warm and Patient #1's "appearance was deceased ". However, CPR efforts were continued and the Patient was transported to the hospital emergency room (ER).

Review of the hospital ER record revealed Patient #1, who was forty-eight (48) years old arrived at 3:50 AM and was pronounced deceased at 3:58 AM.

The facility's failure to to protect and promote patient's rights and prevent neglect of patients placed patients at risk for injury, harm, impairment or death. The facility was notified on 09/30/13 that Immediate Jeopardy was determined to exist. The Immediate Jeopardy was not abated prior to exit on 09/30/13.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of facility policies and procedures, it was determined the facility failed to provide adequate nursing service supervision for one (1) of ten (10) sampled patients (Patient #1). Patient #1 was admitted on [DATE] at 9:30 AM, with diagnoses which included Hypertension, Gastroesophageal Reflux Disease, Psychotic Disorder, Not otherwise specified. Record review revealed Patient #1's pulse was noted to be increased on admission and at other times on 09/21/13 and 09/22/13. According to the vital sign (V/S) policy, licensed staff was to take clinically appropriate action in relation to abnormal findings, recheck V/S within two (2) hours and if the vital signs were still abnormal the Physician was to be notified. Further review of the policy revealed if a patient's pulse range was below 55 or above 105 it was abnormal. Interview with staff revealed Patient #1 was up walking about the unit and conversing with staff and other residents on 09/21/13 and 09/22/13.

Interview with Registered Nurse (RN) #2, the evening shift Medication Nurse, revealed at approximately 9:00 PM on 09/22/13, Patient #1 came to her and requested his/her evening medications. Record review revealed the medications were Colace, Seroquel (an antipsychotic medication), Trazodone (an antidepressant/sleep inducing medication), Lithium (an antipsychotic medication), Omeprazole (a medication used to treat gastroesophageal reflux disease), Carafate (a medication used to treat gastroesophageal reflux disease), Klonopin (a medication used to treat anxiety), Haldol (an antipsychotic medication), and Lactulose (a medication used to prevent constipation). Continued interview with RN #2, the Medication Nurse revealed she informed Patient #1 she had already administered his/her medications. However, at approximately 9:45 PM, she realized she had not administered Patient #1's medications. She stated she obtained the medications and could not get the patient to wake up to take his/her medications. The Medication Nurse indicated she shook Patient #1 and he/she opened his/her eyes, then closed them again. The Medication Nurse stated she poured a couple of drops of water in Patient #1's mouth and he/she opened his/her eyes again, looked at her then closed his/her eyes again and coughed. According to the Medication Nurse, two (2) other patients came in while she was in Patient #1's room and said Patient #1 was "not right ". She stated she went and "got" RN #1, the Charge Nurse.

Interview with RN #1, the Charge Nurse, revealed that two (2) other patients had expressed concern over Patient #1 because he/she had not responded to them. She stated she went to the patient's room to assess him/her and take his/her vital signs (V/S) . She stated Patient #1's V/S were within normal limits, he/she was breathing and there was nothing to be "alarmed" about. RN #1 indicated the Medication Nurse was also in the room and could not get Patient #1 to respond when they shook him/her. RN #1 stated she and the Medication Nurse thought Patient #1 was "playing possum". She stated she did not document her assessment or the V/S.

Interview with Patient #2 revealed on 09/22/13 at approximately 9:30 PM he/she heard the Medication Nurse "yelling" at Patient #1 to wake up over and over. Patient #2 indicated he/she went to Patient #1's room and thought the patient was "unconscious" and his/her eyes were rolling in his/her head. He/She stated the Medication Nurse's attempts to awaken Patient #1 were not successful and he/she informed the Medication Nurse the "rescue squad" needed to be called. Patient #2 stated the Medication Nurse poured Patient #1's medications in his/her mouth and then poured water in the patient's mouth. According to Patient #2, Patient #1 "started strangling" and the Medication Nurse walked out of the room. Patient #2 indicated he/she attempted to roll Patient #1 on his/her side by him/herself; however, was unable to do so. The patient stated he/she went and got Patient #3 to help him/her turn Patient #1 to his/her side. Patient #2 stated they got Patient #1 on his/her side where his/her "airway was clear enough to breathe". He/She stated he/she told the nurses Patient #1 needed to be sent out; however, they did not do so.

Interview with Mental Health Associate (MHA) #1 revealed sometime before 11:30 PM on 09/22/13, she had checked on Patient #1 and he/she was "having trouble breathing". She stated Patient #1 "appeared" to have sleep apnea because he/she stopped breathing for seconds, so she shook him/her and Patient #1 took a "deep breath". MHA #1 stated she reported this information to the Medication Nurse.

Review of the observation checks for the remainder of the night revealed Patient #1 was checked on every fifteen (15) minutes and was sleeping. Interview with MHA #1 revealed she had started the 3:00 AM observation checks at approximately 3:05 AM to 3:07 AM and approximately five (5) to ten (10) minutes later she was in Patient #1's room. According to MHA #1, Patient #1 was not breathing, so she went to get the nurse to check on the patient. MHA #1 stated the nurse checked on the patient and he/she was not breathing. Interview with Registered Nurse (RN) #4, who was present with RN #5 when MHA #1 came to the the nurse's station, revealed she went to the patient's room and shook Patient #1; however, did not get a response. So, she asked MHA #1 to get RN #5; who also came to Patient #1's room, where she and RN #4 performed sternal rubs to elicit a response. This was unsuccessful so RN #4 stated she went and called the Physician and RN #3, who was the Shift Supervisor. According to RN #4, when RN #3 came to the room cardiopulmonary resuscitation (CPR) was initiated and the code blue was called. 911 was called and responded. Patient #1 was transported to a hospital emergency room (ER) where he/she was pronounced deceased at 3:58 AM.

The facility's failure placed, Patient #1, and other patients at risk for injury, harm, impairment or death. The facility was notified on 09/30/13 that Immediate Jeopardy was determined to exist. The Immediate Jeopardy was not abated prior to exit on 09/30/13 and is ongoing. (Refer to A0395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of facility policies and procedures, it was determined the facility failed to ensure nursing service evaluated the care of patients and failed to ensure nursing supervision was adequate for ten (10) of ten (10) sampled patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10).

The facility failed to ensure the Physician was notified of a change in Patient #1's condition, failed to immediately initiate cardiopulmonary resuscitation (CPR) in a patient without a pulse and respirations; and, failed to immediately call a code when Patient #1 was found without a pulse or respirations.

Additionally, the facility failed to ensure patients received the observations as prescribed or indicated for ten (10) of ten (10) sampled patients; and failed to ensure abnormal vital signs (V/S) were rechecked and the Physician notified if the V/S remained abnormal.

The findings include:

Review of the facility's policy, "Assessment and Documentation, Section 3, I. Change in Condition" dated 10/12, revealed the facility recognized and responded to changes in patient's condition. Review revealed an early response to changes in a patient's condition by a specially trained individual may reduce cardiopulmonary arrests and patient mortality. All patients were to be assessed every shift for a change in condition and the Physician was to be notified immediately to significant changes in the patient's condition within the past forty-eight (48) hours. Review of the same policy, at Section 3, C., revealed licensed staff was to take clinically appropriate action related to abnormal findings in vital signs (V/S) and recheck the V/S within two (2) hours to ensure that actions taken had successfully addressed the abnormal findings. Review revealed if upon recheck the V/S remained abnormal the Physician/APRN (Advanced Practice Registered Nurse) was to be notified.

Review of the facility's, "Code Blue" protocol revealed the individual finding the emergency was to call the code, secure emergency equipment to the site of the emergency and initiate cardiopulmonary resuscitation if indicated.

Review of the facility's, "Risk Management Safety Policies, Part C, Patient Supervision", patients are to be observed at specified intervals. Hours of sleep observations from 9:00 PM to 7:30 AM were to be performed every fifteen (15) minutes.

1. Record review revealed Patient #1 was admitted to the facility on [DATE] at 9:30 AM on a seventy-two (72) hour court order related to the patient hearing voices telling him/her to harm his/herself. Record review revealed Patient #1 had diagnoses which included Psychotic Disorder, Not Otherwise Specified (NOS), Hypertension and Gastroesophageal Reflux Disease. Review of Patient #1's vital signs revealed during the time the patient was in triage, prior to being admitted , his/her pulse was 112 beats per minute (bpm). Review of the Registered Nurse (RN) Shift Assessment forms and the Vital Signs, Weight, and Height Record form revealed upon admission to the unit at 9:30 AM, Patient #1's pulse was (125) bpm sitting and (129) bpm standing. Continued review of these documents revealed on 09/22/13 at 6:00 AM, Patient #1's pulse was noted to be (102) bpm sitting and (112) bpm standing; and, at 4:00 PM on that date Patient #1's pulse was documented as (101) bpm sitting and (105) bpm standing. Review revealed Patient #1 had Physician Orders for every fifteen (15) minute observation checks. Further record review revealed Patient #1 experienced a headache on 09/21/13 at 7:40 PM and again on 09/22/13 at 12:00 AM. Tylenol was administered and documented to have been effective.

Interviews, on 09/25/13 with Mental Health Associates (MHAs) #2, #3, #4 and #5 revealed they had cared for and observed Patient #1 on 09/21/13 and 09/22/13. The MHAs stated Patient #1 had been up ambulating on the unit, conversing with staff and other patients. Interviews, on 09/26/13 with MHAs #6 and #7 and on 09/30/13 with MHAs #8 and #10 revealed they also had observed the patient conversing with others and ambulating about the unit.

Interview, on 09/25/13 at 2:40 PM, with Registered Nurse (RN) #6 revealed she was the nurse who admitted Patient #1 to the unit on 09/21/13 at 9:30 AM. She stated Patient #1 had no complaints of shortness of breath, dizziness, and no distress. RN #6 stated Patient #1's vital signs (V/S) were taken and his/her pulse was high; however, she did not recheck the patient's pulse two (2) hours later as per facility policy. She stated the Physician was not notified of Patient #1's increase pulse.

Interview, on 09/30/13 at 2:31 PM, with Physician #1 revealed he had worked 09/21/13 all day and on 09/22/13 until 7:00 PM. He stated he was never informed of Patient #1's increased pulse during the time he was working. Physician #1 stated if nursing staff had called him he would have went and "checked" on the patient.

Interview, on 09/26/13 at 9:33 AM, with Mental Health Associate (MHA) #1 revealed she performed every fifteen (15) minuted observation checks on patients on 09/22/13 and at 3:00 AM on 09/23/13. She stated sometime before 11:30 PM on 09/22/13 she had observed Patient #1 having difficulty breathing. MHA #1 stated she thought Patient #1 "appeared" to have sleep apnea as he/she stopped breathing for seconds. She stated she shook Patient #1 and he/she took a "deep breath". MHA #1 stated she reported this information to Registered Nurse (RN) #2 who was passing medications that night.

Interview, on 09/25/13 at 6:03 PM, with RN #2, who was the evening shift Medication Nurse on 09/22/13, revealed she did not normally work Patient #1's unit and was not familiar with the patients. RN #2 stated Patient #1 walked up to her on 09/22/13 at approximately 9:00 PM and requested his/her evening medications. She stated she had informed Patient #1 that she had already administered his/her evening medications. According to RN #2, at approximately 9:45 PM, she realized she had not administered Patient #1's medications, so she prepared the medications. RN #2 stated she went to the patient's room sometime between 9:45 PM and 10:00 PM and could not get Patient #1 awake to take his/her medications. She stated she shook Patient #1 and he/she opened and closed his/her eyes. RN #2 stated she poured a couple of drops of water in Patient #1's mouth as this was sometimes effective in awakening a patient. She stated Patient #1 opened and closed his/her eyes again and coughed. RN #2 stated two (2) other patients came into Patient #1's room while she was in there and said Patient #1 was "not right ". She stated she then went and "got" RN #1, the Charge Nurse who was the only other nurse working the unit with her.

Interview, on 09/25/13 at 3:35 PM, with RN #1, who was the Charge Nurse, revealed two (2) other patients had come to her and "were in an uproar" because Patient #1 was not responding to them. She stated she went in and took Patient #1's vital signs (V/S) and they were within normal limits. RN #1 stated she thought Patient #1's pulse was 101 bpm. She stated Patient #1 was warm, he/she was breathing and there was nothing to be "alarmed" about. The RN stated RN #2 was also in the room and they attempted to shake Patient #1 awake. However, Patient #1 did not respond at all. She stated she and RN #2 thought Patient #1 was "playing possum", there was nothing to be "alarmed" about so they left the room. RN #1 stated she did not document her assessment or the V/S as there was nothing to be "alarmed" about.

Interview, on 09/26/13 at 10:35 AM, with Patient #2 revealed on 09/22/13 at approximately 9:30 PM he/she heard the Medication Nurse, RN #2 "yelling" at Patient #1 to wake up over and over. Patient #2 stated he/she got up and went to Patient #1's room where he/she saw Patient #1 " unconscious" with his/her "eyes rolling in" his/her head. Patient #2 stated RN #2 could not get Patient #1 to wake up and he/she told RN #2 the "rescue squad" needed to be called. Patient #2 stated RN #2 poured Patient #1's medications in his/her mouth and then poured water in the patient's mouth. According to Patient #2, Patient #1 "started strangling". He/She stated RN #2 walked out of Patient #1's room. Patient #2 stated he/she attempted to roll Patient #1 on his/her side by himself/herself; however, was unable to do so. Patient #2 stated he/she went out of Patient #1's room to find assistance. He/She stated he/she found Patient #3 and they returned to Patient #1's room where they turned Patient #1 on his/her side. Patient #2 stated Patient #1's "airway was clear enough to breathe" after that. Patient #2 stated he/she went and told the nurses Patient #1 needed to be sent out; however, the nurses did not listen to him/her.

Interview, on 09/26/13 at 4:07 PM, with Patient #3 revealed Patient #2 had come to him/her on 09/22/13 around 10:00 to 11:00 PM, and asked him/her to assist with turning Patient #1 on his/her side. He/She stated they went to Patient #1's room where he/she observed Patient #1 choking. Patient #3 stated Patient #2 had told him/her the medication nurse (RN #2) had poured water in Patient #1's mouth causing him/her to choke. Patient #3 indicated he/she and Patient #2 turned Patient #1 on his/her side.

Interview, on 09/30/13 at 2:22 PM, with Physician #2 revealed he was working at 7:00 PM on 09/22/13. He stated he was never informed of staff not being able to awaken Patient #1. Physician #2 stated he had not been informed RN #2 had poured water in Patient #1's mouth. He stated he would have expected to have been notified of these findings and information.

Continued record review revealed observation checks were performed every fifteen (15) minutes and staff noted Patient #1 to be sleeping. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #1 was to have every fifteen (15) minute observation checks performed. Further review of the observation checks revealed no documented evidence observation checks were performed at 9:00 PM, 9:15 PM, and 9:30 PM on 09/22/13.

Interview, on 09/30/13 at 5:35 PM, with the Senior Nurse Administrator (SNA) revealed his expectation was that staff follow facility policy. He stated he was not aware of RN #2 pouring water in Patient #1's mouth and that was something that was not condoned or taught at the facility. The SNA stated if Patient #1 experienced a change in condition the Physician should have been notified. He stated this information should have been reported to the oncoming shift for continued monitoring of the patient. He stated observation checks should be performed as ordered or indicated by the privilege level.

Continued interview, on 09/26/13 at 9:33 AM, with MHA #1 revealed she performed the 3:00 AM observation checks on 09/23/13; however, she did not get started performing them until approximately five (5) to seven (7) minutes after 3:00 AM. She stated her observation check of Patient #1 occurred approximately five (5) to ten (10) minutes later; at approximately 3:12 AM. The MHA stated the patient was not snoring as usual, so she went into Patient #1's room and "shined" her flashlight on him/her. She stated Patient #1 was not breathing, so she shook him/her with no response. MHA #1 indicated she went to the nurse's station and informed RN #5 she thought the patient was not breathing. She stated she thought it was RN #5 who went to check on Patient #1 while she sat at the nurse's station. Continued interview revealed RN #5 returned to the nurse's station and informed MHA #1 to call a "code blue", which she stated she did. MHA #1 stated she could tell "something wasn't right" with Patient #1 when she did her observation check at 3:00 AM. She stated Patient #1's extremities were cold, his/her chest was "somewhat" warm, and his/her eyes were unresponsive to light.

Interview, on 09/30/13 at 3:15 PM, RN #5, who MHA #1 indicated she had asked to check on Patient #1, revealed she had not been informed in report of a change in Patient #1's condition. She stated staff had observed Patient #1 breathing, snoring and he/she was in no distress. RN #5 stated MHA #1 had come to the nurse's station, sometime after 3:00 AM, when she noticed no rising or falling of Patient #1's chest. She stated RN #4 went to the patient's room with MHA #1. According to the RN, MHA #1 came back to the nurse's station and stated RN #4 had requested that she come to Patient #1's room. She stated RN #4 had thought she initially felt a weak pulse, and she observed RN #4 performing sternal rubs (painful stimulus to attempt to get a patient to respond) which she stated had no effect on Patient #1. RN #5 stated she also attempted the sternal rubs with no effect. She stated Patient #1's eyes were "rolled back in" his/her head. RN #5 stated she knew they needed help quickly so she ran out of the room, went to the nurse's station and told MHA #1 to call a "code blue". She stated she went to get the emergency cart and noted MHA #1 having difficulty getting the "code blue" call through. RN #5 stated she went into the medication room to try to get the "code blue" call through and heard the "code blue" call over the intercom. She stated numerous staff arrived from other units to assist with the code. The RN stated Physician #2 also responded to the "code blue". Additionally, RN #5 stated she had MHA #1 call 911.

Interview, on 09/25/13 at 4:15 PM, with RN #4, who was working on 09/22/13 on night shift and was with RN #5 when MHA #1 came to the nurse's station, revealed she had not been informed of staff not being able to awaken Patient #1 on the previous shift. She stated MHA #1 came to the nurse's station during the 3:00 AM observation checks, and stated she was having a "hard time" getting Patient #1 up. The RN stated MHA #1 asked her to come to Patient #1's room to check on him/her. RN #4 stated she went to Patient #1's room and shook Patient #1's arm; however, this did not "rouse" the patient. She stated she asked MHA #1 to get RN #5; who also came to Patient #1's room. RN #4 indicated she and RN #5 both performed sternal rubs; however, this did not elicit a response. RN #4 stated she went and called the Physician and RN #3, who was the Shift Supervisor. She stated she should have called a "code blue" as per facility policy. According to RN #4, when RN #3 came to the room cardiopulmonary resuscitation (CPR) was initiated and the code blue was called. She stated 911 was called; however, could not remember the exact time the call was placed.

Interview, on 09/30/13 at 4:00 PM, with RN #3, who was the Shift Supervisor on 09/22/13 on the night shift, revealed no one on the previous shift had reported anything regarding Patient #1 to her. She stated she was on Patient #1's unit just prior to being called back by RN #4 who informed her they had a "man down". RN #3 stated she thought a patient had fallen and asked RN #4 about this. She stated RN #4 "screamed" at her "we need you down here now". The RN stated she "took off running" to Patient #1's unit. She indicated she went to Patient #1's room and checked for a pulse; however, was unable to get one. RN #3 stated she "screamed" at staff to start CPR, and she started performing mouth-to-mouth respirations on Patient #1 and RN #4 started chest compressions. She stated Patient #1's body temperature was a "little cool", but not cold. RN #3 stated if she had found Patient #1 without respirations or a pulse she would have immediately called a "code blue". She stated Physician #2 came to the "code blue" after it was called and took over the breathing for her. RN #3 stated CPR was performed until Emergency Medical Services (EMS) arrived and took over Patient #1's care.

Review of the Emergency Medical Services (EMS) run sheet revealed the 911 call was received at 3:17 AM and EMS were at Patient #1's bedside at 3:29 AM. Further review of the EMS run sheet revealed Patient #1 was transported to a hospital emergency room (ER). Review of the hospital emergency room (ER) record revealed Patient #1 was pronounced deceased at 3:58 AM.

Interview, on 09/26/13 at 4:30 PM, with the EMS Officer in Charge revealed when emergency personnel arrived at the facility, Patient #1's extremities were cool; his/her "core" was still warm and Patient #1's "appearance was deceased ".

2. Review of Patient #7's medical record revealed an admission date of [DATE] at 8:02 PM with diagnoses which included Schizoaffective Disorder. Review revealed Patient #7's vital signs (V/S) were obtained on 09/20/13 and a pulse noted of (49) beats per minute (bpm) noted. However, there was no documented evidence a recheck of the pulse was performed or that the Physician was notified of this abnormal pulse. On 09/26/13 at 6:00 PM, Patient #7's pulse was documented to be (54) bpm; however, there was no documented evidence of a two (2) hour recheck of the pulse or that the Physician had been notified of the abnormal pulse as per facility policy. On 09/29/13 at 4:00 PM, Patient #7's pulse was noted to be (52) bpm; however, there was no documented evidence of a two (2) hour recheck as per facility policy, and no documented evidence the Physician had been notified of this abnormal pulse.

Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #7 was to have every fifteen (15) minute observation checks performed on 09/19/13. Further review of the observation checks revealed no documented evidence observation checks were performed at 3:00 PM, 3:15 PM, 3:30 PM, 3:45 PM, and 4:45 PM on 09/19/13. Further review of the Patient Supervision Record revealed on 09/26/13 and 09/27/13, Patient #7 was to have every thirty (30) minute observation checks performed until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Record review revealed no documented evidence observation checks were performed every thirty (30) minutes until 9:00 PM and, then every fifteen (15) minutes after 9:00 PM as per facility policy as follows: on 09/26/13 at 12:00 PM, 7:30 PM, and 8:00 PM; on 09/27/13 at 9:00 PM and 9:15 PM.

3. Review of Patient #8's medical record revealed an admission date of [DATE] at 2:30 PM with diagnoses which included Psychotic Disorder, Not Otherwise Specified (NOS). Review revealed Patient #8's vital signs (V/S) were obtained on 09/24/13 at 4:00 PM and a pulse noted of (46) bpm. However, there was no documented evidence a recheck of the pulse was performed or that the Physician was notified of this abnormal pulse. On 09/26/13 at 6:00 PM, Patient #8's pulse was documented to be (49) bpm; however, there was no documented evidence of a two (2) hour recheck of the pulse or that the Physician had been notified of the abnormal pulse. On 09/29/13 at 8:00 AM, Patient #8's pulse was noted to be (42) bpm sitting and, (47) bpm standing; however, there was no documented evidence of a two (2) hour recheck as per facility policy, and no documented evidence the Physician had been notified of this abnormal pulse.

Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #8 was to have every thirty (30) minute observation checks performed on 09/26/13. Further review of the observation checks revealed no documented evidence observation checks were performed on 09/26/13 at 12:00 PM, 7:30 PM, and 8:00 PM.

4. Review of Patient #5's medical record revealed an admission date of [DATE] at 2:00 PM. Review revealed Patient #5's vital signs (V/S) were obtained on 09/23/13 during the 7:00 AM to 3:30 PM shift and a pulse noted of 109 bpm. However, there was no documented evidence a recheck of the pulse was performed as per facility policy or that the Physician was notified of this abnormal pulse.

Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #5 was to have every thirty (30) minute observation checks performed on 09/22/13 until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Further review of the observation checks revealed no documented evidence observation checks were performed on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM, and 9:30 PM.

5. Review of Patient #2's medical record revealed an admission date of [DATE] at 8:00 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #2 was to have every thirty (30) minute observation checks performed on 09/22/13 until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Further review of the observation checks revealed no documented evidence observation checks were performed on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM, and 9:30 PM.

6. Review of Patient #3's medical record revealed an admission date of [DATE] at 3:45 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #3 was to have every fifteen (15) minute observation checks performed on 09/22/13. Further review of the observation checks revealed no documented evidence observation checks were performed every fifteen (15) minutes on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM and 9:30 PM.

7. Review of Patient #4's medical record revealed an admission date of [DATE] at 3:00 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #4 was to have every thirty (30) minute observation checks performed on 09/22/13 until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Further review of the observation checks revealed no documented evidence observation checks were performed on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM, and 9:30 PM.

8. Review of Patient #6's medical record revealed an admission date of [DATE] at 1:00 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #6 was to have every fifteen (15) minutes on 09/22/13. Further review of the observation checks revealed no documented evidence observation checks were performed every fifteen (15) minutes on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM, and 9:30 PM.

9. Review of Patient #9's medical record revealed an admission date of [DATE] at 2:20 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #9 was to have every thirty (30) minute observation checks performed on 09/27/13 until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Further review of the observation checks revealed no documented evidence observation checks were performed every fifteen (15) minutes as per facility policy on 09/27/13 at 9:00 PM, 9:15 PM and 10:00 PM.

10. Review of Patient #10's medical record revealed an admission date of [DATE] at 11:45 PM. Review of the Patient Supervision Record, on which observation checks were documented, revealed Patient #10 was to have every thirty (30) minute observation checks performed on 09/22/13 until 9:00 PM and, every fifteen (15) minutes after 9:00 PM when all patients are observed every fifteen (15) minutes as per facility policy. Further review of the observation checks revealed no documented evidence observation checks were performed on 09/22/13 at 8:30 PM, 9:00 PM, 9:15 PM, and 9:30 PM.

Interview, on 09/30/13 at 5:35 PM, with the Senior Nurse Administrator (SNA) revealed his expectation was that staff follow facility policy regarding checking V/S having abnormals, checking V/S again in two (2) hours, and notifying the Physician if the V/S remained abnormal. He stated observation checks should be performed as ordered or indicated by the privilege level. The SNA stated that all residents receive every fifteen (15) observation checks during the night.

The facility's failure to ensure nursing service evaluated the care of patients and failed to ensure nursing supervision was adequate placed patients at risk for injury, harm, impairment or death. The facility was notified on 09/30/13 that Immediate Jeopardy was determined to exist. The Immediate Jeopardy was not abated prior to exit on 09/30/13.