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.

CYPRESS PSYCHIATRIC HOSPITAL 4363 CONVENTION ST SUITE 1 BATON ROUGE, LA July 5, 2011
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to follow their policy and procedure for investigation of falls as evidenced by failure to complete a Fall Assessment and/or Risk Management Evaluation for 3 of 3 patients identified as having sustained a fall (Patient #1, #5, #7) out of a total sample of 7 medical records. Findings:

Patient #1
Review of the medical record for Patient #1 revealed a [AGE] year old male admitted via PEC (Physician's Emergency Certificate) on 03/27/11 for a long history of bi-polar disorder, medication non-compliance and suicidal ideation.

Review of the Fall assessment dated /timed 03/28/11 at 2000 (8:00pm) revealed patient was on fall precautions, had seizure disorders and a sprained ankle (which was present before the fall). Further review revealed the MD was notified (date, time and name of physician not documented) and the actions taken were pain medication and use of a wheelchair. The hospital could not submit the Risk Management form which should have been completed after the fall according to the hospital's policy.

Review of the 7A-7P Nursing Assessment form for Patient #1 dated/timed 04/22/11 at 0900(9:00am) revealed ......."04/22/11 at 1050 (10:50am) Pt. (Patient) states that he fell while in the dining hall, not witnessed by staff. Pt. states that he tried to stand on his foot to throw a cup in the garbage and fell ". Further review of the medically record revealed no documented evidence Patient #1's ankle was assessed for further injury after the reported fall.

Review of the Transfer Form for Patient #1 dated/timed 04/22/11 at 1300 (1:00pm) revealed.... "Patient's Condition: Vital Signs: B/P (Blood Pressure) space left blank; Pulse space left blank; Respirations space left blank; Temperature space left blank; Clinical Presentation - Pt/ stated tried to stand on LLE and fell . LLE cold to touch, mottled, capillary refill < 3 seconds. Pt. complaining of severe ankle pain".

The hospital could not submit any Risk Management Report for the fall on 04/22/11 for Patient #1.

Patient #5
Review of the medical record of Patient #5 revealed he was a [AGE] year old male admitted to Cypress Psychiatric hospital on [DATE] at 7:10 a.m. The legal status of patient #5 was FVA (formal voluntary admission) with the diagnosis of [DIAGNOSES REDACTED].

In a telephone interview on 06/30/11 at 9:18 am MHT (Mental Health Tech) S7 verified she worked the 7P-7A shift on 06/21/11-06/22/11. S7 indicated she saw Patient #5 fall on 06/22/11 at 0520 (5:20 am) as he (#5) was was coming out of his room. Further S7 indicated Patient #5 fell to a sitting position.

In a face to face interview on 06/30/11 at 9:05 a.m. with RN S2 DON (Director of Nursing)stated the Fall Assessment and Risk Management Report related to the fall of Patient #5 was not complete as of this date.

Patient #7
Review of the medical record for Patient #7 revealed a [AGE] year old male admitted by PEC (Physician Emergency Certificate) for depression with a plan to kill himself. Further review revealed Patient #7 had a history of a craniotomy, closed head injury, seizures, migraine headaches and [DIAGNOSES REDACTED].

Review of the Nursing Assessment form for Patient #7 dated 05/20/11 7A-7P revealed .... 0835 (8:35am) Pt. (Patient) vs (vital signs) WNL (Within Normal Limits) at Level 0. No s/s (signing/symptoms) of HTN (Hypertension) noted. No acid reflex noted. No seizure activity noted. States that his pain is currently controlled, c/o (complained) migraine/head pain rated 4/10. No s/s of withdrawal noted at this time " .

Review of the "Transfer Form" for Patient #7 dated/timed 05/20/11 at 192 (7:35pm) revealed ... Transfer patient for evaluation and treatment of: Pt. (Patient) found unresponsive laying face down, pulse palpable, audible respirations. Pt aroused after oxygen applied, was oriented to person only, confused. Pt. reported pain to head and remembers being dizzy before fall.

The hospital could not provide any documentation a fall had occurred on 05/20/11, the facts related to the fall or an assessment of Patient #7 after the fall. Further the hospital could not submit a Risk Management Report for the fall for Patient #7 on 05/20/11. Review of the medical record revealed no documented evidence Patient #7 had sustained a fall, had been assessed, the MD notified or any further assessments performed.

In a face to face interview on 07/05/11 at 2:00pm RN S2 Director of Nursing indicated she is currently training someone to perform the quality assistance/performance improvement activities previously performed by herself. Further she indicated the nurses should have been completing the Fall Assessment and then forwarding those forms to her office. S2 verified the Risk Evaluations were not performed and therefore the statistical data reported to the QA/PI Committee was inaccurate.

Review of Policy No: 609.1 titled "Patient Falls" last revised 06/07 and submitted by the hospital as the one currently in use, revealed..... "4. If after the indicated precautions have been implemented and the patient does in fact fall, the physician is to be contacted, medical care as needed should be rendered immediately, the fact that the patient fell should be documented in the medical record..... 5. The nurse is to complete a Risk Management Report and Patient Fall Assessment to be forwarded to the Director of Nursing...".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to follow their policy and procedure for implementing an individualized plan of care as evidenced by failing to update a patient's plan of care to reflect changes in condition related to labile blood pressure, mental status and hydration (Patient #5) and non-compliance in the use of a wheelchair due to swelling, redness and pain to the left ankle (Patient #1) for 2 of 7 sampled patients. Findings:

Patient #5
Review of the Multidisciplinary Administration of the Master Treatment Plan revealed the first Treatment Team meeting was held on Monday June 20th, 2011. Review of Patient #5's "Problem List" revealed the following: Priority #1 - Safety - Cocaine Use; Priority #2 - Medical - COPD, CAD, GERD, HTN; Priority #3 - ADL's (activities of daily living) (arrow down) decreased sleep, nutrition.

Review of the Safety Nursing Plan of Care revealed it was last updated 06/20/11. Review of the entire document revealed no update/change to the Care Plan for Patient #5 when he was noticed walking down the hall appearing lethargic and sedated per RN S21 at around 2:00 p.m.

Review of the Medical Nursing Plan of Care revealed the last update was 06/20/11. Review of the entire document revealed no update/change to the Care Plan for Patient #5 when he began experiencing changes in mental status and labile blood pressures on 06/21/11.

Review of the Activities of Daily Living Nursing Plan of Care revealed the last update was 06/20/11. Review of the entire document revealed no update/change to the Care Plan for Patient #5 when he began experiencing changes in intake on 06/21/11.

In a face to face interview on 07/01/11 at 11:00 a.m. RN S2 DON (Director of Nursing)confirmed there was no updates in the care plan to include assessment and identification of new problems for Patient #5, development of a updated plan of care, interventions to address these problems and evaluation of the effectiveness of the plan of care for Patient #5.


Patient #1
Review of the medical record for Patient #1 revealed a [AGE] year old male voluntarily to the hospital on [DATE] for a long history of bi-polar disorder, medication non-compliance and depression. Further Patient #1 was previously discharged from Hospital "a" on 04/08/11 with an appointment to see an orthopedic surgeon for his sprained left ankle (an appointment which he did not keep).

Review of the Nursing Assessment forms dated 04/14/11 through 04/21/11 revealed no documented evidence Patient #1 was non-compliant in the use of his wheelchair which was ordered by his MD due to #1's sprained left ankle. Review of en entry dated 04/22/11 at 1345 (1:45 p.m.) revealed.... Pt. (Patient) refuses to use wheelchair. Up walking on unit. Patient once again informed to put no weight on Left foot and to keep it elevated. Patient states, 'If it falls off, oh well'...".

Review of the Physician's Progress Note dated/timed 04/18/11 at 1445 (2:45 p.m.) revealed Patient #1 did not keep his appointment with the orthopedist and has been walking everywhere on it.

Review of the Multidisciplinary Administration of the Master Treatment Plan for Patient #1 revealed the first Treatment Team meeting was held on 04/18/11. Review of Patient #1's " Problem List" revealed the following: Priority #1 - Safety - Depressed, Delusions, Suicidal Ideations; Priority #2 - Medical - Epilepsy, Hepatitis C, Left Ankle Sprain; Priority #3 - ADL's (activities of daily living) (arrow down) Nutrition, Sleep, Sinus Congestion, Acute Hemorrhoids.

Review of the "Medical Nursing Care Plan" section of the Master Treatment Plan for Patient #1 revealed the care plan was updated on 04/21/11 (the day before Patient #1 was discharged to Hospital "a" for evaluation of his left ankle). Further review revealed no documented evidence the care plan included interventions for the use of a wheelchair, no weight bearing on the left foot, elevation or non-compliance.

In a face to face interview on 07/05/11 at 10:30 a.m. RN S2 DON (Director of Nursing) indicated the Nursing Plan of Care should have been updated to include the interventions as well as interventions to address the patient's non-compliance issues.

Review of Policy No: 201.1 titled "Standards of Care - Nursing" last revised 06/07 and submitted by the hospital as the one currently in use revealed..... "4. Plan of Care: ....The Plan of Care addresses: 4.0 Significant nursing problems identified; 4.1 Measurable short-term goals and long-term goals as indicated with time frames; 4.2 Interventions to promote achievement of goals; 4.2 Individual and disciplines who are responsible for the intervention; and 4.4 The frequency in which the interventions are to be conducted..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) failing to ensure the Registered Nurse conducted an assessment that enables them to recognize the fact that a patient has a need for emergency care for 1 of 7 sampled patients. (Patient #5) (cross reference findings at A0395)

2) failing to ensure the Registered Nurse notified the physician of changes in a patient's medical condition which included labile blood pressures, a change in mental status, and a decreased food and fluid intake for 1 of 7 sampled patients. (Patient #5) (cross reference findings at A0395)

3) failing to ensure the Registered Nurse followed a physician's order to send a patient to the emergency room "now" resulting in a 49 minute delay in calling for ambulance transport for 1 of 7 sampled patients. (Patient #5) (cross reference findings at A0395)

4) failing to ensure the Registered Nurse assessed and documented ongoing assessments of a patient with altered mental status, labile blood pressures, and decreased food and fluid intake for 1 of 7 sampled patients. (Patient #5) (cross reference findings at A0395)

5) failing to ensure the Registered Nurse notified the physician responsible for the care of the patient that the patient had fallen for 1 of 7 sampled patients. (Patient #5) (cross reference findings at A0395)

6) failing to ensure the Registered Nurse notified the physician of a panic lab value for a CO2 value of 14 for a patient experiencing severe anxiety who had to be transferred to a higher level of care (Patient #6) for 1 of 1 patients with a panic value lab out of a total of 7 sampled medical records. (cross reference findings at A0395)

7) failing to ensure the Registered Nurse assessed a patient for a medical condition of a left ankle sprain before and after a reported fall from a wheelchair who had to be transferred to a higher level of care for severe pain, a cold LLE (Left Lower Extremity) and mottled skin (#1) for 1 of 1 patients with a sprained ankle out of 7 sampled medical records. (cross reference findings at A0395)

8) failing to ensure the Registered Nurse assessed patients after a fall for 2 of 3 patients sustaining a fall out of a total sample of 7 medical records. (#1, #7) (cross reference findings at A0395)

9) failing to follow hospital policy and procedure for implementing an individualized plan of care as evidenced by failing to update a patient's plan of care to reflect changes in condition related to labile blood pressure, mental status and hydration (Patient #5) for 1 of 7 sampled patients. (cross reference findings at A0396)

10) failing to follow hospital policy and procedure for implementing an individualized plan of care as evidenced by failing to update a patient's plan of care to reflect non-compliance in the use of a wheelchair due to swelling, redness and pain to the left ankle (Patient #1) for 1 of 7 sampled patients. (cross reference findings at A0396)

11) failing to ensure the Registered Nurse made all patient care assignments based on the needs of the patients as evidenced by: 1) assigning one (1) MHT (Mental Health Tech) every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and an admission of a new patient requiring 25 minutes of 1:1 care resulting in patients failing to be monitored as ordered and 2) assigning one (1) MHT every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and a patient in seclusion who required one to one continuous monitoring (R2) resulting in a break of the continuous monitoring of the seclusion patient in order to check on previously assigned patients for 1 of 7 sampled patients (#5) and 1 Random Patient (R2). (cross reference findings at A0397)

Cypress Psychiatric Hospital was notified of a determination of Immediate Jeopardy. S2DON was informed of the following at 2:40 p.m. on 07/01/11:

The Immediate Jeopardy Situation began on 6/21/11 at 2:25 pm when the hospital failed to ensure a patient's nursing plan of care was updated to include interventions for monitoring a patient with labile blood pressures, a change in mental status, and a decreased fluid intake. The hospital further failed to ensure the physician was notified timely on 6/22/2011 when the patient continued with labile blood pressure, and lethargy. The Registered Nurse failed to notify EMS for 49 minutes following receipt of a telephone order from the physician to transport the patient to the Emergency Department now. Upon arrival to the hospital EMS personnel found a Mental Health Technician in the room with the patient alone attempting a sternal rub to obtain a response from the patient. EMS Personnel immediately recognized the patient was not breathing and initiated a Code Blue which lasted 30 minutes after which the patient was pronounced dead.

On 07/05/11 at 1415 (2:15 p.m.) the Immediate Jeopardy was lifted after the hospital submitted a Plan of Removal (POR). The POR included, but was not limited to the following:

Policy and Procedure revisions with in-service training conducted on 06/30/11, 07/01/11, 07/02/11, 07/03/11, 07/04/11 and will be on-going each shift or daily to assure all staff are educated regarding policy, forms, and practice changes. 80% of the education will be completed by July 8, 2011. Those employees not yet educated will not be allowed to work until education completed. In-service training areas include: Medical Assessment-Intervention/Treatment; Patient Care Memo, Medical Emergencies, Lab Orders/Specimen Collections, Monitoring of Seclusion/Restraints, Post-Mortem Care, Change of Shift Report, Fall Precautions/Risk Management Forms, Fall Precautions Monitoring, and Physical Status Monitoring.

Revision of the Physical Status Monitoring Policy, policy number: 621.1 which revised Vital Signs parameters to be in agreement with the current Clinical Practice Guideline Reference book available to nurses and referenced in hospital Policy and Procedure. This revision also eliminated the gap in policy direction to nursing in regards to Systolic Blood Pressures between 85 mm/Hg and 90 mm/Hg, a pulse rate between 90/min and 100/min, and Temperature between 96.5 and 96.9. In addition the policy revision addressed the need to assess the patient and report any findings outside of the hospital policy normal range to the physician immediately.

Change of Shift Report Policy, policy number RA-1, was revised to ensure the accuracy of the Acuity of the Milieu and Patient (AMP) levels for staffing.

The deficient practice remains at a Condition Level non-compliance.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the Registered Nurse made all patient care assignments based on the needs of the patients as evidenced by: 1) assigning one (1) MHT (Mental Health Tech) every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and an admission of a new patient requiring 25 minutes of 1:1 care (#R1) resulting in patients failing to be monitored as ordered and 2) assigning one (1) MHT every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and a patient in seclusion who required one to one continuous monitoring (R2) resulting in a break of the continuous monitoring of the seclusion patient in order to check on previously assigned patients for 1 of 7 sampled patients (#5) and 1 Random Patient (R2). Findings:

1) assigning one (1) MHT (Mental Health Tech) every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and an admission of a new patient requiring 25 minutes of 1:1 care resulting in patients failing to be monitored as ordered
Patient #5
Review of the Daily Staffing sheet for 06/22/11 revealed that there were two MHT's assigned to work the 7A-7P shift with a third MHT being called in at 1050 (10:50am). Review of the "Shift Amp Level And Staffing Report" revealed MHT S15 was assigned the patients in the Acute Close Observation Beds (rooms closest to the nursing station) and MHT S14 was assigned the remaining patients. Review of the assignments revealed Patient #5 was included in the assignments for MHT S14.

Review of the medical record of Random Patient R1 revealed she was admitted to Cypress Psychiatric hospital on [DATE] at 12:50 p.m.. Review of the Observation Flow Sheet for patient #R1 revealed S14MHT documented in the 1245 (12:45 p.m.) time slot "new admit." In the "Notes" section S14MHT documented "1250 (12:50 p.m.) New Admit." Further review of the Observation Flow Sheet revealed the following documentation by S14MHT: "1300 (1:00 p.m.) L (location) 13 (Admit Room) Activity 7 (with staff), initialed by S14MHT; 1315 (1:15 p.m.) L (location) 13 (Admit Room) Activity 7 (with staff), initialed by S14MHT; 1330 (1:30 p.m.) L (location) 13 (Admit Room) Activity 7 (with staff), initialed by S14MHT. Review of the Vital Signs Record revealed documentation for 06/22/11 at 1250 (12:50 p.m.) that S14MHT had taken and recorded vital signs on patient #R1. Review of the "Admission Inventory Sheet of Valuables and Restricted Items" reveled that patient #R1 and S14MHT signed for the disposition of #R1's personal items at 1315 (1:15 p.m.).

In an interview on 06/30/11 at 8:50 a.m. with S14MHT he stated he worked the 7A - 7P shift on 06/22/11. S14MHT confirmed documentation on the medical record of patient #R1 that he (S14MHT) was involved in the admission of patient #R1 on 06/22/11 from 1250 (12:50 p.m.) to 1315 (1:15 p.m.). S14MHT confirmed that the documentation on the Observation Flow Sheet for 1300 (1:00 p.m.) and 1315 (1:15 p.m.) was added after patient #5 was deceased as S14MHT was in another patients room.

In an interview on 07/01/11 at 9:30 a.m. the staff assignment for 06/22/11 was reviewed. S12RN and S2DON confirmed that S14MHT was assigned a Line of Sight monitoring of a patient (#R2) in seclusion at 10:15 a.m. on 06/22/11 in addition to his previously assigned patients. S2DON stated that the RN Charge Nurse is responsible for staff assignments. S2DON and S12RN confirmed that there was no documented evidence of which staff member was assigned the rooms previously assigned to S14MHT, which included patient #5's room.

2) assigning one (1) MHT every 15 minute observation checks on at least 8 patients, including a patient with a change in condition (#5), and a patient in seclusion who required one to one continuous monitoring.

Random Patient 2

Review of the Daily Staffing sheet for 06/22/11 revealed that there were two MHT's assigned to work the 7A-7P shift. Review of the "Shift Amp Level And Staffing Report" revealed MHT S15 was assigned the patients in the Acute Close Observation Beds (rooms closest to the nursing station) and S14MHT was assigned the remaining patients. Review of the assignments revealed patient #5 was included in the assignments for MHT S14. Further review of the report revealed in addition to the patients requiring every 15 minute checks, S14 was assigned a LOS (Line of Sight) observation at 10:15 a.m.. The hospital could submit no documented evidence the Registered Nurse had re-assigned S14MHT's previously assigned patients to another staff member.

Review of the Observation Flow Sheet revealed Patient R2 was in the seclusion room at 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.). Further review revealed the documented Observation status for Patient R2 was LOS (Line of Sight). S14MHT initialed the Observation Flow Sheet indicating he was the person performing the continuous Line of Sight Observation on Patient R2.

Review of the Observation Flow Sheet for Patient #5 revealed the q 15 minute checks were documented as performed by MHT S14 for 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In a face to face interview on 06/30/11 at 8:50 a.m. MHT S14 confirmed that on 06/22/11 at 10:15 a.m. that he (S14) was assigned a seclusion patient (R2) requiring Line of Sight Observation in addition to his other assigned patients on q 15 minute checks. S14MHT stated that he broke the Line of Sight Observation of patient R2 to perform the q 15 minute checks at 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.) for his other assigned patients which included Patient #5.

In a face to face interview on 07/01/11 at 9:30 a.m. the staff assignment sheet for 06/22/11 was reviewed by RN S12 and RN S2 DON and both confirmed MHT S14 was assigned Line of Sight monitoring for Random Patient (R2) in seclusion at 10:15 a.m. on 06/22/11 in addition to his previously assigned patients. RN S2 DON stated that the RN Charge Nurse was the person responsible for staff assignments. S2DON and S12RN confirmed that there was no documented evidence of which staff member was assigned the rooms previously assigned to MHT S14, which included Patient #5's room.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure RN supervision of care as evidenced by:

1) failing to ensure the Registered Nurse:

a) conducted an assessment that enables them to recognize the fact that a patient has a need for emergency care (Patient #5)

b) notified the physician of changes in a patient's medical condition which included labile blood pressures, a change in mental status, and a decreased food and fluid intake (Patient #5);

c) followed a physician's order to send a patient to the emergency room "now" resulting in a 49 minute delay in calling for ambulance transport (Patient #5);

d) assessed and documented ongoing assessments of a patient with altered mental status, labile blood pressures, and decreased food and fluid intake (Patient #5);

e) notified the physician responsible for the care of the patient that the patient had fallen for 1 of 7 sampled patients. (Patient #5);

2) failing to ensure the Registered Nurse notified the physician of a panic lab value for a CO2 value of 14 for a patient experiencing severe anxiety who had to be transferred to a higher level of care (Patient #6) for 1 of 1 patients with a panic value lab out of a total of 7 sampled medical records;

3) failing to assess a patient for a medical condition of a left ankle sprain before and after a reported fall from a wheelchair who had to be transferred to a higher level of care for severe pain, a cold LLE (Left Lower Extremity) and mottled skin (#1) for 1 of 1 patients with a sprained ankle out of 7 sampled medical records; and

4) failing to assess patients after a fall for 2 of 3 patients sustaining a fall out of a total sample of 7 medical records. (#1, #7)

Findings:

1) Patient #5

Review of the medical record of patient #5 revealed he was a [AGE] year old male admitted to Cypress Psychiatric hospital on [DATE] at 7:10 a.m. The legal status of patient #5 was FVA (formal voluntary admission). Review of the "Psychiatric Initial Doctor's Order Set" (admission orders), taken as a verbal order from S8MD by S17RN on 06/17/11 at 0710 (7:10 a.m.), revealed an admission diagnosis of Depression/Anxiety.

Review of medication orders dated 06/17/11 at 2005 (8:05 p.m.) revealed medication orders from the psychiatrist (S8MD) that were taken as a verbal order by S17RN that included: Ambien 10 mg po qhs (bedtime); Elavil 100 mg po qhs; Xanax 1 mg po tid; Depakote ER 500 mg po qAM (each morning); Depakote ER 1000 mg po qhs; and D/C (discontinue) Ambien CR allergy.

Review of the "Medical Initial Doctors Order Set", taken as a verbal order from S10MD by S12RN on 06/17/11 at 0830(8:30 a.m.) included documented Medical Diagnosis of HTN (hypertension), Arthritis, CAD (coronary artery disease), and GERD (gastroesophageal reflux disease). Vital signs were ordered to be taken upon admission, QID (four times daily) X (times) 24 hours, then once per shift and prn (as needed).

Review of the medication orders written by S10MD on 06/17/11 revealed the following medications were included in the physician's medication orders: Metoprolol 25 mg (milligrams) po (by mouth) BID (twice a day); and Trental 400 mg ER (extended release) po TID (three times daily).

Review of the Psychiatric Evaluation, signed by S8MD on 06/19/11 at 0640 (6:40 a.m. - the last two numbers are illegible) revealed in part: "II ...states he is feeling tired. He feels confused ...VI. Mental Status Evaluation. Appearance: Appropriate. Attitude: Cooperative. Motor Activity: Slow. Affect: Constricted. Mood: Depressed. Speech: Soft...Orientation: Fully Oriented...XI. Precautions: Q 15 minute checks for safety and behavior."

Review of the History and Physical by S10MD dated 06/17/11 at 0945 (9:45 a.m.) revealed in part: "Patient states he is confused and disorganized and felt need to come to hospital. Recently dehydrated and required IV (intravenous) fluids in (name of hospital). He was dehydrated and fell in yard and re-injured neck. Feels he is not safe to go home. Pt. has an extensive medical history. He is an apparently accurate historian...HTN: occasionally, CAD: CABAB [sic] (coronary artery bypass graft), COPD (chronic obstructive pulmonary disease), GI (gastrointestinal): heartburn, MS (musculoskeletal): back pain, PSYC: (none checked), PVD (peripheral vascular disease): on Rx (prescription), Dyslipidemia: on Rx...stent left leg and needs one in right leg. PSH (past surgical history): Cervical spine fusion, Stent Lt. (left) leg, CABAG [sic - CABG]...Meds: Metoprolol...Trental...PHYSICAL EXAMINATION: Well developed, adequately nourished, no acute physical distress. Vital signs: BP (blood pressure): 118/79, P (pulse): 100, T (temperature): 97.1 (no documentation of where obtained), RR (respiratory rate): 18...WT (weight): 176 lbs. (pounds)...Lungs: sl. (slight) wheezing...Impression/Plan: Axis I - II defer to psychiatry. Axis III. 1. HTN - Rx monitor. 2. CAD - Monitor..."

Review of the "Adult Admission Data Base" (initial nursing assessment) revealed in part: "admitted : 06/17/11. Admission Time: 0710 (7:10 a.m.). Admission Status: FVA (formal voluntary admission). Admit Vital Signs: B/P: 118/79. Pulse: 100. Resp: 18. Temp: 97.1...Weight: 176 Lbs...Patient non-verbal/confused (check box - is not checked)...Allergies: Yes. Drugs: Ambien CR...Fall Risk Assessment* - *Sum 6 or greater trigger fall risk. On diuretics/anti hypertensive - 3; Sight/Hearing Deficit - 4; Has fallen before - 7. Total - 14 ...Fall Precautions Implemented: (check boxes) Red Armband, Education, Non-Skid footwear...Review of Systems:..Cardiac: Regular rate and rhythm. Respiratory: Even/Unlabored...Neuro: Blackouts - 06/16/11...Medical Diagnosis/Concerns: (check boxes) HTN, CAD. Other: Fusion of C1 and C2 in 1982 or 83. Pulse Ox (pulse oximetry) (all patients with respiratory/cardiac issues) - blank. MENTAL STATUS EXAM. (check boxes) Orientation: Person, Place, Time. Appearance: Clean...Behavior: Cooperative...Thought Processes: confused at times...Functional Assessment: Ambulation: Self. Toileting: Self. Bathing: Self. Dressing: Self. Feeding: Self. Focus of Initial Plan of Care: Risk: (check boxes) To Self. Medical: Falls...Recommended Observation Level: (check box) 15 minute checks. RISK ASSESSMENT...Physical Assessment of Risk (PAR) Score. (PAR - Physical Assessment of Risk. Includes Consciousness/Cognitive score of 0 (awake, alert) - 2 (stuporous/Profound Mental Retardation or Autistic), Medical Treatment score of 0 (No secondary Diagnosis or medical treatments ordered) to 2 (complex medical treatments or medical monitoring), Vital Signs score of 0 (normal) to 2 (B/P: systolic > 160 or < 80, diastolic < 50 or > 110, P: >110 or < 55, R: >30 or <10, T: >102 or <96.0 = Need Intervention, refer to policy, and Ability to Conduct ADL's (activities of daily living) scored 0 (self or only requires encouragement) to 2 (total care). Total PAR score of 0 - 7 (level 1), 8 - 14 (level 2), 15 - 21 (level 3). This score is factored into staffing.) CONSCIOUSNESS/COGNITIVE. (only those circled are listed) Confused, disoriented, or mild-moderate MR (mental retardation), has disability that minimally affects treatment - 1; MEDICAL TREATMENT. Fall Precautions - 1; Simple medical monitoring (pain, somatic symptoms, etc.) - 1; VITAL SIGNS. Level 1 - (B/P: 120/80 - 90/60, P: 65 - 90, R: 14 - 24, T: 96.9 - 100.0) - 0; ABILITY TO CONDUCT ADL's - 0; TOTAL PAR SCORE - 3. Physical Assessment Risk Level: (check box) 0 - 7 (level 1). Nursing Narrative Summary: Arrived on unit ambulating, alert. States he is confused at times and was at (name of hospital) ER on yesterday he had a blackout. States he cannot remember to take his medications. His wife told him he had been talking to the wall. Also states he has not been sleeping for the last 4 days..." The document is dated 06/17/11 at 0930 (9:30 a.m.) and signed by S12RN.

Review of the Nursing Assessment for 06/17/11 7P - 7A shift documented at 2040 (8:40 p.m.) by S17RN revealed patient #5 was scored a 3 on his PAR score, the same as the initial assessment. Mental Status documentation revealed that patient #5 was Oriented to Person, Place and Time. Thought Content is documented as Organized. Review of the Observation Flow Sheet for patient #5 revealed documentation that the patient consumed 75% of Breakfast, 100% of Lunch, 50% of Dinner and 100% of his HS (bedtime) snack.

Review of the Admit Assessment, 7P - 7A Nursing Assessment, and Shift Vital Signs revealed the following Vital Signs were documented for patient #5 on 06/17/11: 0710 (7:10 a.m.) Admit Assessment: BP 118/79, P 100, RR 18. 1600 (4:00 p.m.) BP 136/92, P 90, RR 18. The 06/17/11 Nursing Assessment Vital Signs documented by S17RN at 2040 (8:40 p.m.) are the same as the Vital Signs documented at 4:00 p.m. on the Vital Signs Sheet, 2400 (12:00 p.m.) BP 123/74, P 80, RR 16.

Documentation for the 06/18/11 7A - 7P shift for patient #5 at 0920 (9:20 a.m.) by S11RN revealed Vital Signs were: BP 103/69, P 73, and RR 18. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 0500 (5:00 a.m.) PAR score remained at 3. Mental Status was Oriented to Person, Place, Time and Situation. Thought content was documented as Organized.

Review of the documentation by S17RN for the 06/18/11 7P - 7A Nursing Assessment, timed at 1920 (7:20 p.m.) revealed patient #5's Vital Signs were: BP 100/52, P 78, RR 20. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 1600 (4:00 p.m.) Review of the PAR score revealed patient #5 now had a score of 4, reflecting a change in score for Vital Signs from 0 to 1. "Recheck" is handwritten as the reason for the score change. Review of the MAR (medication administration record) for 06/18/11 at 2100 (9:00 p.m.) revealed documentation that the BP of patient #5 was rechecked (BP medications to be administered) and was documented to be 108/72 and P 76. Review of the "Additional Progress Notes" on the back of the Nursing Assessment Form revealed documentation by S17RN that read: "2100 (9:00 p.m.) BP recheck 108/72. Pulse 72. Will monitor." The physician ordered Metoprolol and Trental were documented as administered to patient #5. Further review of the 06/18/11 7P - 7A Nursing Assessment under Mental Status revealed patient #5 was Oriented to Person, Place and Time and Thought Content was Organized. Documentation on the Observation Flow Sheet revealed documentation for 06/18/11 that patient #5 consumed 100% of Breakfast, 100% of Lunch, 100% of Dinner, and 100% of his HS snack.

Documentation for the 06/19/11 7A - 7P shift for patient #5 at 0800 (8:00 a.m.) by S16RN revealed Vital Signs were: BP 103/69, P 70, and RR 18. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 0500 (5:00 a.m.) PAR score remained at 3. Mental Status was Oriented to Person, Place, and Time. Thought content was documented as Somatic and Slowed.

Documentation for the 06/19/11 7P - 7A shift for patient #5 at 2032 (8:32 p.m.) by S5RN revealed Vital Signs were: BP 115/65, P 73, and RR 18. PAR score remained at 3. Mental Status was Oriented to Person and Place. Thought content was documented as "forgetful." Further review of the Nursing Assessment under Documentation Related to Medical Issues revealed "BP taken at 2100 (9:00 p.m.) = 104/65, BP medications put on hold per MD." Review of the Shift Vital Signs report for 06/19/11 at 2000 (8:00 p.m.) revealed patient #5 weighed 187 pounds, an increase of 11 pounds since admission on 06/17/11. Review of the Doctor's Order Sheet revealed an order on 06/19/11 at 2105 (9:05 p.m.) from S10MD, taken as a verbal order by S24LPN, that read: "Hold Blood Pressure Medication tonight only." Review of the MAR revealed documentation that the Metoprolol 25 mg po bid and Trental 400 mg ER po tid were circled (indicating held) for the 2100 (9:00 p.m.) dose on 06/19/11. Further review revealed the BP of patient #5 was documented on the MAR as 94/58. Review of the back of the MAR revealed the following documentation by S24LPN that read: "06/19/11 2100 (9:00 p.m.) Hold Blood Pressure meds tonight only. B/P (arrow down) 93/51 per MD." Review of the Nursing Assessment, Observation Flow Sheet and Shift Vital Signs Report revealed no documented evidence that the BP of patient #5 was rechecked until 06/20/11 at 0500 (5:00 a.m.). Further review revealed no documented evidence that the physician was notified of patient #5's 11 pound weight gain in 48 hours and 50 minutes since admission. Review of the Observation Flow Sheet revealed patient #5 had consumed 50% of Breakfast, 85% of Lunch, 45% of Dinner and 100% of his HS snack.

In an interview on 06/29/11 at 8:30 a.m. with S5RN she confirmed she was the RN Charge Nurse and that she worked the 7P - 7A shift on 06/19/11. S5RN confirmed that "confused" was added to the shift report for patient #5 on the 06/19/11 7P - 7A report. S5RN stated that this shift report was given to the 06/20/11 day shift. S5RN denied she added the word "confused" to patient #5's status.

Documentation for the 06/20/11 7A - 7P shift for patient #5 at 0800 (8:00 a.m.) by S12RN revealed Vital Signs were: BP 98/61, P 69, and RR 18. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 0500 (5:00 a.m.) PAR score was now a 2. Review of the CONSCIOUSNESS/COGNITIVE section revealed S12RN had scored patient #5 a "0" (Awake, alert), lowering his score by 1. Mental Status was Oriented to Person and Place. Thought content was documented as Organized. Further review of the Shift Vital Signs Report revealed the BP of patient #5 was documented to be 90/64 at 1600 (4:00 p.m.). Review of the MAR revealed no documented evidence that the BP of patient #5 was checked prior to the 1400 (2:00 p.m.) administration of Trental 400 mg po.

Review of the documentation by S17RN for the 06/20/11 7P - 7A Nursing Assessment, timed at 2035 (8:35 p.m.) revealed patient #5's Vital Signs were: BP 90/64, P 72, RR 20. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 1600 (4:00 p.m.). Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S17RN had scored patient #5 a "0" (Awake, alert); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, a 1 for Simple Medical Treatments, and a 1 for Simple Medical monitoring (pain, somatic s/s (signs and symptoms, etc.) for a total PAR score of 3. Mental Status is documented as Oriented to Person, Place, and Time. Thought Content is documented as Somatic. Review of the Observation Flow Sheet revealed documentation that patient #5 had consumed 90% of Breakfast, 95% of Lunch, 90% of Dinner and 100% of his HS snack.

Documentation for the 06/21/11 7A - 7P shift for patient #5 at 0730 (7:30 a.m.) by S21RN revealed Vital Signs were: BP 104/61, P 76, and RR 19. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 0500 (5:00 a.m.). Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S21RN had scored patient #5 a "0" (Awake, alert); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, a 1 for Simple Medical Treatments, and a 1 for Simple Medical monitoring (pain, somatic s/s (signs and symptoms, etc.) for a total PAR score of 3. Mental Status is documented as Oriented to Person, Place, and Time. Thought Content is not documented.

Review of the Doctor's Order Sheet revealed the following orders on 06/21/11: 0747 (7:47 a.m.) written by S8MD that read: "D/C Xanax. Xanax 1 mg po q AM and q 1400 (2:00 p.m.)." 1440 (2:40 p.m.) "Hold Xanax 1 mg po for now." This order was taken as a verbal order from S8MD by S18RN. 1445 (2:45 p.m.) "Hold Trental 400 mg po tid X 24 hrs (hours)." This order was taken as a verbal order from S9MD by S18RN.

Review of the back of the MAR revealed the following: "06/21/11 1440 (2:40 p.m.) Hold Xanax 1 mg po for now; pt lethargic, per MD." Review of the back of the next page of the MAR revealed: "06/21/11 1445 (2:45 p.m.) Hold Trental ER 400 mg po X 24 hr. (hours) B/P 93/51 per MD."

In an interview on 06/29/11 at 1:10 p.m. with S21RN she confirmed she worked the 7A - 7P shift on 06/21/11 and that she was present for shift report on the morning of 06/22/11 prior to being sent home. S21RN stated that patient #5 was alert and oriented for the morning assessment she performed on 06/21/11. S21RN stated that before the 2:00 p.m. medication pass patient #5 was walking down the hall and he seemed lethargic and sedated. S21RN stated she asked the medication nurse (S18RN) what the patient received earlier. S21RN stated S18RN advised her that patient #5 was given Xanax. S21RN stated she asked S18RN to notify the physician that patient #5 was lethargic and sedated. S21RN stated S8MD gave an order to "hold Xanax for now" and S9MD gave an order to "hold Trental for 24 hours." S21RN stated that patient #5 "mostly stayed in his room." S21RN was present for the morning shift report on 06/22/11 prior to being sent home. S21RN provided notes taken by her on the morning of 06/22/11. The notes for patient #5 included: "last night/fell last night/Lethargy/ 80/40 98/68."

Documentation for the 06/21/11 7P - 7A shift for patient #5 at 2100 (9:00 p.m.) by S5RN revealed Vital Signs were: BP 100/62, P 77, and RR 18. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 1600 (4:00 p.m.). Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S5RN had scored patient #5 a "0" (Awake, alert); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, a 1 for Simple Medical Treatments, and a 1 for Simple Medical monitoring (pain, somatic s/s (signs and symptoms, etc.) for a total PAR score of 3. Medical Treatment Mental Status is documented as Oriented to Person, Place, and Time. Thought Content is documented as organized. Review of the Observation Flow Sheet revealed patient #5 had consumed 60% of Breakfast, 40% of Lunch, 0% of Dinner and 0% of his HS snack. Review of the notes section on the Observation Flow Sheet revealed S7MHT documented "pt ate 0% snack but 40% of his dinner and drank 100% drink and also Coke ordered per MD. Pt. became unsteady and fell in doorway of room." Further review of the documentation under "DOCUMENTATION RELATED TO MEDICAL ISSUES" revealed S5RN documented "2108 (9:08 p.m.) Manual BP check 91/52. Order received to hold Metoprolol 25 mg and Trental 400 mg and give patient 12 ounces of Coca-Cola per Dr. (S9MD). 2110 (9:10 p.m.) (2 minutes after previous documentation) Vital Signs conducted after meal and Coke intake. BP 111/71, P 78, R 18, T 97.4. MD notified of current status." Review of the MAR revealed documentation that the Metoprolol and Trental due for 06/21/11 at 2100 (9:00 p.m.) were held (circled) and that the BP of patient #5 was 83/51 (no time this BP was taken). Review of the Doctor's Order sheet revealed there was no documented evidence of any order received from S9MD on the night shift of 06/21/11. Further review of the 06/21/11 Night Shift Nursing Assessment revealed no further documentation of the blood pressure of patient #5 until 0500 (5:00 a.m.) on 06/22/11. Documentation for 06/22/11 at 0500 (5:00 a.m.) on both the Nursing Assessment under "Additional Progress Notes" and the Shift Vital Signs revealed patient #5's BP was 131/89, P 82, R 18.

In an interview on 06/29/11 at 8:30 a.m. with S5RN she stated she worked the 7P - 7A shift on 06/21/11 - 06/22/11. S5RN confirmed she was the Charge Nurse. S5RN confirmed the documentation timed 2108 (9:08 p.m.) that read: "Manual BP check 91/52. Order received to hold Metoprolol 25 mg and Trental 400 mg and give patient 12 ounces of Coca-Cola per (S9MD)." S5RN stated she took a manual BP because she noticed the BP documented on the MAR for the 9:00 p.m. meds of 83/51. S5RN confirmed the order received from S9MD was not documented on the Doctor's Order Sheet. S5RN documented at 2110 (9:10 p.m.) that repeat vital signs conducted after meal and Coke intake were BP 111/71, P 78, R 18, and that the MD (no documentation of which MD) was notified of current status. S5RN confirmed that there were no further vital signs documented for patient #5 between 2110 (9:10 p.m.) and 0500 (5:00 a.m.). S5RN stated she checked the BP of patient #5 during this time but did not document the findings. S5RN stated that at 0520 (5:20 a.m.) she was notified by S7MHT that patient #5 was attempting to exit his room and fell . S5RN stated that she notified S9MD that patient #5 had fallen but did not document the notification. S5RN reviewed the shift report created for her off-going report to the day shift of 06/22/11. S5RN confirmed the report now had "6/21/11 - Pt. very lethargic and drowsy, falling asleep at mealtime, MD order to hold Xanax R/T (related to) altered mental status. MD order to hold Trental r/t low BP" listed for patient #5. S5RN denied that she made this entry and denied knowing how this information got onto the shift report. S5RN further confirmed that there is no documented evidence that she reported to the 06/22/11 on-coming shift that patient #5 had fallen at 0520 (5:20 a.m.) on 06/22/11.

In a telephone interview on 06/30/11 at 9:18 a.m. with S7MHT she stated she worked the 7P - 7A shift on 06/21/11 - 06/22/11. S7MHT stated she saw patient #5 fall on 06/22/11 at 0520 (5:20 a.m.). S7MHT stated patient #5 was coming out of his room and fell to a sitting position.

Documentation for the 06/22/11 7A - 7P shift for patient #5 at 0900 (9:00 a.m.) by S12RN revealed Vital Signs were: BP 92/62, P 100, and RR 20. Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S12RN had scored patient #5 a "1" (Lethargic - responds to verbal stimuli); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, under Vital Signs patient #5 was given no score as a Pulse Rate of 100 falls below a "0" score for 65 - 90 and above a Level 1 of > 100, (Level 1 Vital Signs score requires "Recheck and/or Monitor") for a total PAR score of 3. Mental Status is documented as Oriented to Person and Place. Mood/Behavior is documented as "Other: Lethargic." Thought Content is documented as slowed. There is no documented evidence of notification of the physician responsible for the care of patient #5 of his change in mental status. Review of the narrative documentation (no time) by S12RN under "DOCUMENTATION RELATED TO RISK" revealed "Alert oriented to person, place. Responding slower today. Denies HI (homicidal ideations) or SI (suicidal ideations). Affect sad. States he is OK but noted to be lethargic." Under "DOCUMENTATION RELATED TO MEDICAL ISSUES" S12RN documented (no time documented) "Pt B/P reported to be (arrow down) during the night. At present is 92/62. Denies any resp. (respiratory) distress or heart burn. Night nurse reported pt. had fall last night. Presently pt. is lethargic. Sat on side of bed and drank sm. (small) amt. (amount) of H20." Under "Additional Progress Notes" the following documentation was entered by S12RN: "1000 (10:00 a.m.) Instructed med (medication) nurse not to administer any B/P meds or any meds due to pt. being lethargic and B/P already low. Will monitor and recheck pt. B/P. 1030 (10:30 a.m.) B/P 88/56. Pt. remains in bed stating not hungry. Will cont (continue) to encourage po fluids. Taking water but in not drinking Ensure [?] with encouragement. Heart rate 102. Resp 20. 1130 (11:30 a.m.) Still not eating but taking sm. Amt. of H2O. 1205 (12:05 a.m.) B/P remains low. Lung congestion and [?] in (arrow up - upper) and (arrow down - lower) lobes anterior and posterior. Dr. (S8MD) notified of pt. condition. Instructed to notify Dr. (S9MD) who gave order to transfer pt. to (hospital "a") ER for eval. 1210 (12:10 p.m.) (Ambulance service "a") called by unit clerk. Report called to the nurse @ (at) the ER. 1230 (12:30 p.m.) Pt. in bed not taking anything po @ this time. Cont. to say OK when asked how he feels. Resp even and unlabored. Awaiting ambulance for transport. 1301 (1:01 p.m.) (Ambulance Service "a") here @ this time. MHT in room. Pt. arrested. CPR started. 1331 (1:31 p.m.) (Ambulance Service "a") notified (S3MD) @ (hospital "a") of pt. no response to CPR. Stated was instructed to stop CPR @ this time. 1335 (1:35 p.m.) (S9MD) and (S8MD) notified of pt. death. 1448 (2:48 p.m.) (S9MD) present at this time."

Review of the Doctor's Order Sheet revealed an order for 06/22/11 at 1205 (12:05 p.m.), taken as a verbal order from S8MD by S12RN that read: "Transfer to (hospital "a") ER (emergency room ) for Evaluation."

Review of a Physician's Progress Note documented by S8MD on 06/22/11 at 0808 (8:08 a.m.) read in part: "Pt states that he feels tired this am. Told pt that his blood pressure was low. Talking (illegible - about?) follow up..."

Review of a Physician's Progress Note documented by S9MD on 06/22/11 at 2:48 p.m. read as follows: "called to notify about patient death. Notified had low BP pressure, no chest pains or any other distress. Last BP - 88/56 and patient was lethargic. Had instructed to transport patient to ER ASAP. Called back when EMS (ambulance service "a") came. Patient was in Resp (respiratory) distress and states coding (arrow to right) CPR (cardiopulmonary resuscitation) performed and was not responding to resuscitation and ended code. Patient at this time pulseless and pupils nonreactive and 0 HR (heart rate). Pronounced dead at 2:48 p.m."

In an interview on 06/28/11 at 9:55 a.m. with S12RN she stated that she worked the 7A - 7P shift on 06/22/11 and confirmed she was the RN Charge Nurse. S12RN stated she did see the printed shift report and got a verbal report that patient #5 had low blood pressure on the night before and was informed blood pressure medications were being held. S12RN also stated that she was told that patient #5 had fallen on the night shift of 06/21/11 - 06/22/11. S12RN stated she was told the physician was notified on the night shift of 06/21/11 - 06/22/11 and that an order to hold BP meds was obtained. S12RN confirmed that there was no order documented on the night shift of 06/21/11 to hold BP meds. S12RN stated that S14MHT told her on the morning of 06/22/11 "go check on Mr. (patient #5), he did not get up this morning." S12RN confirmed that she documented patient #5 was "noted to be lethargic" on the assessment documented for 9:00 a.m. on 06/22/11 and she did not notify the physician of the change in status of patient #5. S12RN further confirmed that she spoke to patient #5 at 9:00 a.m., that he "did not seem the same" and that she did not notify the physician. S12RN stated that she did not know if patient #5 hit his head when he fell at 5:20 a.m. on 06/22/11. S12RN confirmed that no Neurological checks were performed or documented on patient #5. S12RN confirmed her documentation of "pt. presently lethargic." S12RN confirmed she did not check the patient's blood sugar, perform any intervention, or notify the physician. S12RN stated she thought patient #5 was dehydrated. S12RN stated she did not perform orthostatic blood pressures. S12RN was asked to review her 10:00 a.m. documentation to hold all meds. S12RN stated she did notify the physician but failed to document any contact with the physician. S12RN stated she directed S18RN to recheck the blood pressure of patient #5 at 10:30 a.m. S12RN reviewed her documentation timed at 10:30 a.m. and stated that she was not informed of patient #5's blood pressure being 88/56 until 11:30 a.m. S12RN stated that she documented the time she instructed S18RN to recheck the BP and not the time she was informed of the results. S12RN stated that according to her 11:30 a.m. documentation the patient (#5) was "taking sm. (small) amt. (amount) of H2O" that she notified S8MD but failed to document any contact with the psychiatrist. Review of the Vital Signs Record revealed that S12RN had entered a set of Vital Signs for patient #5 timed at 11:00 a.m. (BP 90/60, P 100) and 12:00 a.m. (BP 90/60, P 100) with her signature next to each. S12RN stated "I do not know who took those vital signs - I know I took one of them." S12RN was asked why she called the physician at 12:05 p.m. if she had obtained a set of vital signs before S18RN informed her of the 88/56 and one set of vital signs after. S12RN stated that she notified S8MD at 12:05 p.m. "because (patient #5)'s blood pressure was staying low." S12RN stated S8MD told her "maybe he needs an IV, call (S9MD)." S12RN stated that S9MD told her to transfer patient #5 to hospital "a" ER. Review of the Doctor's Order Sheet and review of the Nursing Progress Note both contain documentation that S9MD had given an order to transfer patient #5 to the ER at 12:05 p.m. on 06/22/11. S12RN stated that S13Unit Clerk called Ambulance Service "a" and that she (S12RN) did not speak to the Ambulance Service. S12RN stated that S13Unit Clerk informed her that an ambulance "would be here within the hour." S12RN confirmed that she did not assign any staff member to stay with/monitor patient #5. S12RN stated she "was in the room 5 times between 9:00 a.m. and 12:05 p.m." S12RN stated that when she saw the Ambulance Service arrive she instructed S15MHT to get a set of vital signs. S12RN stated that S15MHT and the Ambulance personnel entered the room at about the same time. S12RN stated she was then informed that the Ambulance personnel were starting CPR. S12RN was asked when was the last time someone was in the room prior to arrival of the Ambulance. S12RN stated she was the last one in the room at 12:30 p.m. (31 minutes prior to Ambulance arrival) S12RN stated she did not nor did she assign anyone to monitor patient #5 continuously. S12RN stated the B/P was only taken twice (documented at 11:00 a.m. and 12:00 a.m. by S12RN) between S18RN taking it at 10:30 a.m. and 1301 (1:01 p.m.). S12RN was asked if patient #5 had a BP of 88/56, HR of 102, and was lethargic, did she think he had a medical emergency, she replied "Yes", but I was not informed of BP until 11:30 a.m. S12RN was asked why she did not call the physician or an ambulance then. S12RN replied "I don' t recall, I had a couple of things going on."

On 07/01/11 at 9:30 a.m., after the audio tape from Ambulance Service "a" was obtained and reviewed, S12RN was re-interviewed. S12RN now stated that she had taken both the 11:00 a.m. and the 12:00 a.m. blood pressures on patient #5. S12RN again stated that she called the physician at 12:05 p.m. because patient #5's blood pressure remained low. S2DON was present and stated the physician should have been notified of the change in mental status of patient #5. S12RN now stated that she "did not remember if it was (Ambulance Service "a")" that was called. (there are two providers in the area) S12RN stated that the call was for a "routine transfer." S12RN stated that patient #5 was "not the same - but he was saying he was OK." S12RN was presented with the documented evidence that Ambulance Service was called at 12:53:37 and the review of the audio tape. S12RN stated the time was incorrect and denied the call was 48 minutes and 37 seconds after the physician ordered the transfer of patient #5 to the ER. S12RN was asked about her statements that patient #5 "has a decrease in level of consciousness ...he's not really responding at this point, blood pressure's real low; his last blood pressure was 88/55 ...(dispatch) so you want this STAT? (S12RN) "Yes ..." and the earlier reply of "now" as to when the transport was needed. S12RN stated she did not state the patient was emergent but she did want the transport "now."

In an interview on 06/28/11 at 11:10 a.m. with S18RN she confirmed she worked the 7A - 7P shift on 06/22/11 as the medication nurse. S18RN stated that she was told in shift report by the off going staff that patient #5 had low blood pressure the night before. S18RN stated she did not remember if the exact BP was mentioned. S18RN stated that S25LPN informed her that patient #5 had also fallen during the night shift. S18RN confirmed that she documented on the back of the MAR the following: "06/22/11 0900 (9:00 a.m.) Medication held / pt. unable to arouse. CN (charge nurse) and MD notified. Pt responded by saying 'what, yum-huh, OK'." S18RN further stated that this documentation indicating that the physician was notified is incorrect as she never notified the physician. S18RN stated that sometime near the morning medication time she
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview the hospital failed to follow their policy and procedure for accuracy of entries into the medical record as evidenced by: 1) an admit assessment indicating the patient had no Gastro-Intestinal problems (nausea and vomiting) and documentation in the progress note indicated the patient was nauseated and vomiting, was documented as being completed at the same time (Patient #6); 2) an admit assessment indicating a patient was exhibiting signs of tremors and an Abnormal Involuntary Movement Scale assessment indicating the patient had no abnormal movements, documented as being completed at the same time (Patient #6); and 3) implementing a nursing assessment form which the hospital did not require the nursing staff to authenticate after each entry for 7 of 7 sampled medical records (Patient #1, #2, #3, #4, #5, #6. #7) Findings:

1) an admit assessment indicating the patient had no Gastro-Intestinal problems which included nausea and vomiting an was and progress note indicating the patient was nauseated and vomiting, documented as being completed at the same time
Patient #6
Review of the "Adult Admission Data Base" form dated 05/14/11 at 0735 (7:35am) described Patient #6 as currently exhibiting withdrawal symptoms of tremors, nausea, vomiting and anxiety; his skin was pale and diaphoretic; even and unlabored respirations; and with no GI (Gastrointestinal) difficulties (nausea/vomiting/diarrhea).

RN S22, the nurse performing the assessments, was no longer employed by the hospital and could not be contacted for an interview.

In a face to face interview on 07/05/11 at 2:00pm RN 2 Director of Nursing reviewed the "Adult Admission Data Base" form dated 05/14/11 at 0735 (7:35am) and the nursing progress note dated/timed 05/14/11 at 0740 (7:40 a.m.) and could not explain the inaccuracy in the assessment performed by the nurse.

Review of Policy No: 201.1 titled "Standards of Care- Nursing", last revised 06/07 and submitted by the hospital as the one currently in use, revealed..... "Nursing documentation is clear, legible, concise and reflects the ongoing plan of care and the patient's response to intervention.....".


2) an admit assessment indicating a patient was exhibiting signs of tremors and an Abnormal Involuntary Movement Scale assessment indicating the patient had no abnormal movements, documented as being completed at the same time
Patient #6
Review of the "Adult Admission Data Base" form dated 05/14/11 at 0735 (7:35am) described Patient #6 as currently exhibiting withdrawal symptoms of tremors.

Review of the AIMS Assessment (Abnormal Involuntary Movement Scale for Patient #6 dated/timed 05/14/11 at 0740 (7:40 a.m.) revealed no abnormal movements noted.

In a face to face interview on 07/05/11 at 2:00pm RN 2 Director of Nursing reviewed the "Adult Admission Data Base" form dated 05/14/11 at 0735 (7:35am) and the AIMS Assessment (Abnormal Involuntary Movement Scale dated/timed 05/14/11 at 0740 (7:40 a.m.) for Patient #6 and could not explain the inaccuracy in the assessment performed by the nurse.


3) implementing a nursing assessment form which the hospital did not require the nursing staff to authenticate after each entry
Review of the 7A-7P and 7P-7A Nursing Assessment forms for Patients #1, #2, #3, #4, #5, #6 and #7 revealed no documented evidence each entry into the progress notes was dated, timed or signed.

In a face to face interview on 07/01/11 at 10:30 a.m. RN S2 Director of Nursing indicated the nurse assigned to the patient signed his/her name on the front of the form. Further S2 indicated, after review of the nursing assessment form, the date, time and signature of the person making the entry should have been included.

Review of Policy No: 209.1 titled "Patient Charting/Documentation", last revised 06/07 and submitted by the hospital as the one currently in use, revealed.... "Procedure: 2. All entries should be dated and timed. 3. Identify all notations with signature and title of recorder..."
VIOLATION: EMERGENCY SERVICES Tag No: A0093
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the Registered Nurse assessed/reassessed a patient to identify the need for emergency care, failed to follow hospital policy to involve the physician in the appraisal of the need for emergency care and/or medical direction in a timely manner, and failed to recognize when the patient's needs exceeded the hospital's capabilities for 1 of 7 sampled patients. (patient #5) This was evidenced by failure of the Registered Nurse to notify the physician responsible for the care of the patient of altered mental status, labile blood pressures, and decreased intake and failure of the Registered Nurse to follow a physician order to transfer a patient to the emergency room (ER) "now" by having a 49 minute delay in calling for transport of the patient to the ER. Findings:

Patient #5

Documentation for the 06/21/11 7P - 7A shift for patient #5 at 2100 (9:00 p.m.) by S5RN revealed Vital Signs were: BP 100/62, P 77, and RR 18. Review of the Shift Vital signs report revealed these Vital Signs were documented as taken at 1600 (4:00 p.m.). Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S5RN had scored patient #5 a "0" (Awake, alert); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, a 1 for Simple Medical Treatments, and a 1 for Simple Medical monitoring (pain, somatic s/s (signs and symptoms, etc.) for a total PAR score of 3. (PAR - Physical Assessment of Risk. Includes Consciousness/Cognitive score of 0 (awake, alert) - 2 (stuporous/Profound Mental Retardation or Autistic), Medical Treatment score of 0 (No secondary Diagnosis or medical treatments ordered) to 2 (complex medical treatments or medical monitoring), Vital Signs score of 0 (normal) to 2 (B/P: systolic > 160 or < 80, diastolic < 50 or > 110, P: >110 or < 55, R: >30 or <10, T: >102 or <96.0 = Need Intervention, refer to policy, and Ability to Conduct ADL's (activities of daily living) scored 0 (self or only requires encouragement) to 2 (total care). Total PAR score of 0 - 7 (level 1), 8 - 14 (level 2), 15 - 21 (level 3). This score is factored into staffing.) Medical Treatment Mental Status is documented as Oriented to Person, Place, and Time. Thought Content is documented as organized. Review of the Observation Flow Sheet revealed patient #5 had consumed 60% of Breakfast, 40% of Lunch, 0% of Dinner and 0% of his HS snack. Review of the notes section on the Observation Flow Sheet revealed S7MHT documented "pt ate 0% snack but 40% of his dinner and drank 100% drink and also Coke ordered per MD. Pt. became unsteady and fell in doorway of room." Further review of the documentation under "DOCUMENTATION RELATED TO MEDICAL ISSUES" revealed S5RN documented "2108 (9:08 p.m.) Manual BP check 91/52. Order received to hold Metoprolol 25 mg and Trental 400 mg and give patient 12 ounces of Coca-Cola per Dr. (S9MD). 2110 (9:10 p.m.) (2 minutes after previous documentation) Vital Signs conducted after meal and Coke intake. BP 111/71, P 78, R 18, T 97.4. MD notified of current status." Review of the MAR revealed documentation that the Metoprolol and Trental due for 06/21/11 at 2100 (9:00 p.m.) were held (circled) and that the BP of patient #5 was 83/51 (no time this BP was taken). Review of the Doctor's Order sheet revealed there was no documented evidence of any order received from S9MD on the night shift of 06/21/11. Further review of the 06/21/11 Night Shift Nursing Assessment revealed no further documentation of the blood pressure of patient #5 until 0500 (5:00 a.m.) on 06/22/11. Documentation for 06/22/11 at 0500 (5:00 a.m.) on both the Nursing Assessment under "Additional Progress Notes" and the Shift Vital Signs revealed patient #5's BP was 131/89, P 82, R 18.

In an interview on 06/29/11 at 8:30 a.m. with S5RN she stated she worked the 7P - 7A shift on 06/21/11 - 06/22/11. S5RN confirmed she was the Charge Nurse. S5RN confirmed the documentation timed 2108 (9:08 p.m.) that read: "Manual BP check 91/52. Order received to hold Metoprolol 25 mg and Trental 400 mg and give patient 12 ounces of Coca-Cola per (S9MD)." S5RN stated she took a manual BP because she noticed the BP documented on the MAR for the 9:00 p.m. meds of 83/51. S5RN confirmed the order received from S9MD was not documented on the Doctor's Order Sheet. S5RN documented at 2110 (9:10 p.m.) that repeat vital signs conducted after meal and Coke intake were BP 111/71, P 78, R 18, and that the MD (no documentation of which MD) was notified of current status. S5RN confirmed that there were no further vital signs documented for patient #5 between 2110 (9:10 p.m.) and 0500 (5:00 a.m.). S5RN stated she checked the BP of patient #5 during this time but did not document the findings. S5RN stated that at 0520 (5:20 a.m.) she was notified by S7MHT that patient #5 was attempting to exit his room and fell . S5RN stated that she notified S9MD that patient #5 had fallen but did not document the notification. S5RN reviewed the shift report created for her off-going report to the day shift of 06/22/11. S5RN confirmed the report now had "6/21/11 - Pt. very lethargic and drowsy, falling asleep at mealtime, MD order to hold Xanax R/T (related to) altered mental status. MD order to hold Trental r/t low BP" listed for patient #5. S5RN denied that she made this entry and denied knowing how this information got onto the shift report. S5RN further confirmed that there is no documented evidence that she reported to the 06/22/11 on-coming shift that patient #5 had fallen at 0520 (5:20 a.m.) on 06/22/11.

In a telephone interview on 06/30/11 at 9:18 a.m. with S7MHT she stated she worked the 7P - 7A shift on 06/21/11 - 06/22/11. S7MHT stated she saw patient #5 fall on 06/22/11 at 0520 (5:20 a.m.). S7MHT stated patient #5 was coming out of his room and fell to a sitting position.

Documentation for the 06/22/11 7A - 7P shift for patient #5 at 0900 (9:00 a.m.) by S12RN revealed Vital Signs were: BP 92/62, P 100, and RR 20. Review of the PAR score revealed the CONSCIOUSNESS/COGNITIVE section revealed S12RN had scored patient #5 a "1" (Lethargic - responds to verbal stimuli); under Medical Treatment patient #5 was scored a 1 for Fall Precautions, under Vital Signs patient #5 was given no score as a Pulse Rate of 100 falls below a "0" score for 65 - 90 and above a Level 1 of > 100, (Level 1 Vital Signs score requires "Recheck and/or Monitor") for a total PAR score of 3. Mental Status is documented as Oriented to Person and Place. Mood/Behavior is documented as "Other: Lethargic." Thought Content is documented as slowed. There is no documented evidence of notification of the physician responsible for the care of patient #5 of his change in mental status. Review of the narrative documentation (no time) by S12RN under "DOCUMENTATION RELATED TO RISK" revealed "Alert oriented to person, place. Responding slower today. Denies HI (homicidal ideations) or SI (suicidal ideations). Affect sad. States he is OK but noted to be lethargic." Under "DOCUMENTATION RELATED TO MEDICAL ISSUES" S12RN documented (no time documented) "Pt B/P reported to be (arrow down) during the night. At present is 92/62. Denies any resp. (respiratory) distress or heart burn. Night nurse reported pt. had fall last night. Presently pt. is lethargic. Sat on side of bed and drank sm. (small) amt. (amount) of H20." Under "Additional Progress Notes" the following documentation was entered by S12RN: "1000 (10:00 a.m.) Instructed med (medication) nurse not to administer any B/P meds or any meds due to pt. being lethargic and B/P already low. Will monitor and recheck pt. B/P. 1030 (10:30 a.m.) B/P 88/56. Pt. remains in bed stating not hungry. Will cont (continue) to encourage po fluids. Taking water but in not drinking Ensure [?] with encouragement. Heart rate 102. Resp 20. 1130 (11:30 a.m.) Still not eating but taking sm. Amt. of H2O. 1205 (12:05 a.m.) B/P remains low. Lung congestion and [?] in (arrow up - upper) and (arrow down - lower) lobes anterior and posterior. Dr. (S8MD) notified of pt. condition. Instructed to notify Dr. (S9MD) who gave order to transfer pt. to (hospital "a" ) ER for eval. 1210 (12:10 p.m.) (Ambulance service "a" ) called by unit clerk. Report called to the nurse @ (at) the ER. 1230 (12:30 p.m.) Pt. in bed not taking anything po @ this time. Cont. to say OK when asked how he feels. Resp even and unlabored. Awaiting ambulance for transport. 1301 (1:01 p.m.) (Ambulance Service "a" ) here @ this time. MHT in room. Pt. arrested. CPR started. 1331 (1:31 p.m.) (Ambulance Service "a" ) notified (S3MD) @ (hospital "a" ) of pt. no response to CPR. Stated was instructed to stop CPR @ this time. 1335 (1:35 p.m.) (S9MD) and (S8MD) notified of pt. death. 1448 (2:48 p.m.) (S9MD) present at this time."

Review of the Doctor's Order Sheet revealed an order for 06/22/11 at 1205 (12:05 p.m.), taken as a verbal order from S8MD by S12RN that read: "Transfer to (hospital "a" ) ER (emergency room ) for Evaluation."

Review of a Physician's Progress Note documented by S8MD on 06/22/11 at 0808 (8:08 a.m.) read in part: "Pt states that he feels tired this am. Told pt that his blood pressure was low. Talking (illegible - about?) follow up..."

Review of a Physician's Progress Note documented by S9MD on 06/22/11 at 2:48 p.m. read as follows: "called to notify about patient death. Notified had low BP pressure, no chest pains or any other distress. Last BP - 88/56 and patient was lethargic. Had instructed to transport patient to ER ASAP. Called back when EMS (ambulance service "a" ) came. Patient was in Resp (respiratory) distress and states coding (arrow to right) CPR (cardiopulmonary resuscitation) performed and was not responding to resuscitation and ended code. Patient at this time pulseless and pupils nonreactive and 0 HR (heart rate). Pronounced dead at 2:48 p.m."

In an interview on 06/28/11 at 9:55 a.m. with S12RN she stated that she worked the 7A - 7P shift on 06/22/11 and confirmed she was the RN Charge Nurse. S12RN stated she did see the printed shift report and got a verbal report that patient #5 had low blood pressure on the night before and was informed blood pressure medications were being held. S12RN also stated that she was told that patient #5 had fallen on the night shift of 06/21/11 - 06/22/11. S12RN stated she was told the physician was notified on the night shift of 06/21/11 - 06/22/11 and that an order to hold BP meds was obtained. S12RN confirmed that there was no order documented on the night shift of 06/21/11 to hold BP meds. S12RN stated that S14MHT told her on the morning of 06/22/11 "go check on Mr. (patient #5), he did not get up this morning." S12RN confirmed that she documented patient #5 was "noted to be lethargic" on the assessment documented for 9:00 a.m. on 06/22/11 and she did not notify the physician of the change in status of patient #5. S12RN further confirmed that she spoke to patient #5 at 9:00 a.m., that he "did not seem the same" and that she did not notify the physician. S12RN stated that she did not know if patient #5 hit his head when he fell at 5:20 a.m. on 06/22/11. S12RN confirmed that no Neurological checks were performed or documented on patient #5. S12RN confirmed her documentation of "pt. presently lethargic." S12RN confirmed she did not check the patient's blood sugar, perform any intervention, or notify the physician. S12RN stated she thought patient #5 was dehydrated. S12RN stated she did not perform orthostatic blood pressures. S12RN was asked to review her 10:00 a.m. documentation to hold all meds. S12RN stated she did notify the physician but failed to document any contact with the physician. S12RN stated she directed S18RN to recheck the blood pressure of patient #5 at 10:30 a.m. S12RN reviewed her documentation timed at 10:30 a.m. and stated that she was not informed of patient #5's blood pressure being 88/56 until 11:30 a.m. S12RN stated that she documented the time she instructed S18RN to recheck the BP and not the time she was informed of the results. S12RN stated that according to her 11:30 a.m. documentation the patient (#5) was "taking sm. (small) amt. (amount) of H2O" that she notified S8MD but failed to document any contact with the psychiatrist. Review of the Vital Signs Record revealed that S12RN had entered a set of Vital Signs for patient #5 timed at 11:00 a.m. (BP 90/60, P 100) and 12:00 a.m. (BP 90/60, P 100) with her signature next to each. S12RN stated "I do not know who took those vital signs - I know I took one of them." S12RN was asked why she called the physician at 12:05 p.m. if she had obtained a set of vital signs before S18RN informed her of the 88/56 and one set of vital signs after. S12RN stated that she notified S8MD at 12:05 p.m. "because (patient #5)'s blood pressure was staying low." S12RN stated S8MD told her "maybe he needs an IV, call (S9MD)." S12RN stated that S9MD told her to transfer patient #5 to hospital "a" ER. Review of the Doctor's Order Sheet and review of the Nursing Progress Note both contain documentation that S9MD had given an order to transfer patient #5 to the ER at 12:05 p.m. on 06/22/11. S12RN stated that S13Unit Clerk called Ambulance Service "a" and that she (S12RN) did not speak to the Ambulance Service. S12RN stated that S13Unit Clerk informed her that an ambulance "would be here within the hour." S12RN confirmed that she did not assign any staff member to stay with/monitor patient #5. S12RN stated she "was in the room 5 times between 9:00 a.m. and 12:05 p.m." S12RN stated that when she saw the Ambulance Service arrive she instructed S15MHT to get a set of vital signs. S12RN stated that S15MHT and the Ambulance personnel entered the room at about the same time. S12RN stated she was then informed that the Ambulance personnel were starting CPR. S12RN was asked when was the last time someone was in the room prior to arrival of the Ambulance. S12RN stated she was the last one in the room at 12:30 p.m. (31 minutes prior to Ambulance arrival) S12RN stated she did not nor did she assign anyone to monitor patient #5 continuously. S12RN stated the B/P was only taken twice (documented at 11:00 a.m. and 12:00 a.m. by S12RN) between S18RN taking it at 10:30 a.m. and 1301 (1:01 p.m.). S12RN was asked if patient #5 had a BP of 88/56, HR of 102, and was lethargic, did she think he had a medical emergency, she replied "Yes" , but I was not informed of BP until 11:30 a.m. S12RN was asked why she did not call the physician or an ambulance then. S12RN replied "I don' t recall, I had a couple of things going on."

On 07/01/11 at 9:30 a.m., after the audio tape from Ambulance Service "a" was obtained and reviewed, S12RN was re-interviewed. S12RN now stated that she had taken both the 11:00 a.m. and the 12:00 a.m. blood pressures on patient #5. S12RN again stated that she called the physician at 12:05 p.m. because patient #5's blood pressure remained low. S2DON was present and stated the physician should have been notified of the change in mental status of patient #5. S12RN now stated that she "did not remember if it was (Ambulance Service "a")" that was called. (there are two providers in the area) S12RN stated that the call was for a "routine transfer." S12RN stated that patient #5 was "not the same - but he was saying he was OK." S12RN was presented with the documented evidence that Ambulance Service was called at 12:53:37 and the review of the audio tape. S12RN stated the time was incorrect and denied the call was 48 minutes and 37 seconds after the physician ordered the transfer of patient #5 to the ER. S12RN was asked about her statements that patient #5 "has a decrease in level of consciousness ...he's not really responding at this point, blood pressure's real low; his last blood pressure was 88/55 ...(dispatch) so you want this STAT? (S12RN) "Yes ..." and the earlier reply of "now" as to when the transport was needed. S12RN stated she did not state the patient was emergent but she did want the transport "now."

In an interview on 06/28/11 at 11:10 a.m. with S18RN she confirmed she worked the 7A - 7P shift on 06/22/11 as the medication nurse. S18RN stated that she was told in shift report by the off going staff that patient #5 had low blood pressure the night before. S18RN stated she did not remember if the exact BP was mentioned. S18RN stated that S25LPN informed her that patient #5 had also fallen during the night shift. S18RN confirmed that she documented on the back of the MAR the following: "06/22/11 0900 (9:00 a.m.) Medication held / pt. unable to arouse. CN (charge nurse) and MD notified. Pt responded by saying 'what, yum-huh, OK'." S18RN further stated that this documentation indicating that the physician was notified is incorrect as she never notified the physician. S18RN stated that sometime near the morning medication time she instructed S14MHT to take BP's on a list of patients who were to receive medications that required BP checks prior to administration. S18RN stated that the list was returned to her by S14MHT with the BP's written on the paper. S18RN stated that she could not recall what the documented BP for patient #5 was, but added that it caused her to go take a manual BP. S18RN stated the BP of patient #5 was 88/56 with a heart rate of 102. S18RN RN stated she reported this BP to S12RN within 15 - 20 minutes of 10:30 a.m. S18RN stated that in addition to informing S12RN she asked if the physician should be called. S18RN stated that she was told by S12RN to recheck patient #5's BP. S18RN stated she rechecked patient #5's BP twice and stated she could not remember what it was nor did she document the BP. S18RN stated that when the Code Blue was called she was near the nurses' station as were S12RN, S16RN, and S13Unit Clerk.

In an interview on 06/28/11 at 2:20 p.m. with S13Unit Clerk she stated she worked on 06/22/11 from 7A - 7P. S13Unit Clerk stated that she placed the call to Ambulance Service "a". S13Unit Clerk stated her only conversation with Ambulance Service "a" was "I am calling from Cypress Psychiatric Hospital to have a patient transferred to (hospital "a") ER" and that she handed the phone to S12RN. S13 stated "all I know is the patient had a low BP." S13Unit Clerk stated that S15MHT went down the hall with the Ambulance personnel and then shouted out to call a Code Blue. S13Unit Clerk stated that S12RN worked on the transfer paperwork for "about 20 minutes" after receiving the order from S9MD to transfer patient #5 to the ER. In a second interview with S13Unit Clerk on 06/29/11 at 11:45 a.m. she confirmed that she signed the q 15 minute Observation Flow Sheet for 1100 (11:00 a.m.), 1115 (11:15 a.m.) and 1130 (11:30 a.m.) on 06/22/11. S13Unit Clerk stated that S15MHT was involved in an altercation with a patient (#R2) and S14MHT was assisting so she did the Observations. S13Unit Clerk stated that on one of the checks S18RN was in the room offering Ensure to patient #5. S13Unit Clerk stated that patient #5 was seated on the edge of the bed and he was "unable to sit upright, he was wobbling" and that he laid back down. Another interview was conducted with S13Unit Clerk on 07/01/11 at 10:20 a.m. with S2DON present. S13Unit Clerk stated that S12RN told her to "call (ambulance service "a") to have (patient #5) transferred." S13Unit Clerk stated that she called the "transfer" number and not 911. S13Unit Clerk stated that she was asked by the ambulance call taker if "within the hour" was ok. S13Unit Clerk stated she asked S12RN if that was OK and S12RN replied "now." S13Unit Clerk stated that after the order to transfer patient #5 to the ER by S9MD that she (S13) went to the "back" (administrative area) to copy paperwork and S12RN worked on the transfer form for about 15 minutes. S13 stated that S12RN then instructed her to call the ambulance to transport patient to (hospital "a") ER.

In an interview on 06/29/11 at 8:00 a.m. with S15MHT he confirmed he worked the 7A - 7P shift on 06/22/11. S15MHT stated he was assigned the area closest to the nursing station and that patient #5 was assigned to S14MHT. S15MHT stated he was told by off-going S7MHT that patient #5 was "lethargic but arousable." S15MHT stated he overheard that patient #5 had a low BP from S12RN and S6RN. S15MHT stated he received no report of patient #5 falling on the previous shift and had only learned of the fall on 06/28/11. S15MHT stated that when Ambulance Service "a" arrived that S12RN said "go get a quick set of vital signs" on patient #5. S15MHT stated this was near 1:00 p.m. S15MHT stated he got a vital signs machine and entered the room of patient #5 just prior to the crew from Ambulance Service "a". S15MHT stated he lifted the arm of patient #5 and found him "flaccid." S15MHT stated he wrapped the BP cuff around the arm of patient #5. S15MHT stated he noticed no rise and fall of the chest and performed a sternal rub on patient #5, getting no response. S15MHT stated that Ambulance Service "a" personnel entered the room and stated "the patient is not breathing" and S15MHT stated he responded "I know." The patient was moved to the floor, CPR started, and a Code Blue was called. S15MHT confirmed S12RN and S16RN were at the nurses' station when he advised them of the Code Blue. S15MHT stated he was assigned hall monitoring prior to the Code Blue and no one had entered the room of patient #5 for at least 10 minutes.

In an interview on 06/28/11 at 2:40 p.m. with S14MHT he stated he worked the 7A - 7P shift on 06/22/11. S14MHT stated that he learned of patient #5's fall from reading the shift report. (there was no documentation of the fall on the shift report) S14MHT stated he took patient #5's BP per request of the medication nurse (S18RN) at around 8:15 a.m. and indicated it was low, "around 90/60" but could not remember exactly. S14MHT confirmed this BP was not documented. S14MHT stated patient #5 was "disoriented." S14MHT stated he told S12RN Charge Nurse "somebody needs to go check on (patient #5)." S14MHT stated he gave the BP reading to S18RN on the paper containing the names of patients given to him by S18RN. S14MHT stated patient #5 missed breakfast and stayed in his room. S14MHT stated he became aware that an ambulance was being called for patient #5 when he overheard S13Unit Clerk say on the phone "no you need to come now." S14MHT was re-interviewed on 06/30/11 and confirmed documentation on the medical record of patient #R1 that he (S14MHT) was involved in the admission of patient #R1 on 06/22/11 from 1250 (12:50 p.m.) to 1315 (1:15 p.m.). S14MHT confirmed that the documentation on the Observation Flow Sheet for 1300 (1:00 p.m.) and 1315 (1:15 p.m.) was added after patient #5 was deceased as S14MHT was in another patients room. S14MHT further stated that he did perform the q 15 minute observations on patient #5 between 11:45 a.m. and 12:45 p.m. S14MHT stated patient #5 was lying on the bed for each observation and that no one else entered the room of patient #5 during that time.

In an interview on 06/29/11 at 2:05 p.m. with S9MD she stated that when she came to the hospital on [DATE] at 2:48 p.m. and pronounced patient #5 deceased that his body was on the floor of the room. S9MD stated that the order she gave to S18RN on 06/21/11 was "hold all medications that could cause sedation and all blood pressure medications." S9MD stated she was contacted during the evening on 06/21/11 regarding the blood pressure of patient #5. S9MD stated she told the nurse "I had ordered BP meds held, give him a Coke." S9MD stated she was not notified that patient #5 fell at 5:20 a.m. on 06/22/11. S9MD stated that when S12RN called her at 12:05 p.m. on 06/22/11 regarding patient #5 that she instructed S12RN to "put the phone down and call an ambulance and send him (#5) to the ER." S9MD stated her intent was an Emergent transport. S9MD stated she would expect continuous monitoring of patient #5 while waiting for the Ambulance. S9MD stated she would have sent patient #5 to the ER earlier if she was notified of his condition. S9MD stated she would expect nursing to do Neurological checks and check the capillary blood sugar of patient #5. S9MD stated she was not informed of the 88/56 BP of patient #5 as documented on the back of the MAR.

In an interview on 06/30/11 at 9:05 a.m. with S2DON she stated that no investigation into the events surrounding the death of patient #5 had been done as of this date. S2DON stated the incident report related to the fall of patient #5 was not complete as of this date.

In an interview on 07/01/11 at 11:00 with S2DON she stated that any Registered Nurse (RN) should be able to recognize a medical emergency. S2DON stated that on 06/22/11 the RN's failed to recognize a medical emergency for patient #5. S2DON stated the physician should have been notified of the status of patient #5 at 9:00 a.m. S2DON stated that she would expect 911 to be called based upon the physicians order and the condition of patient #5.

Review of the Doctor's Order Sheet revealed S9MD gave an order for patient #5 to be sent to Hospital "a" to S12RN at 12:05 p.m. on 06/22/11. Review of an audio tape of that call and information on the Medical Record generated by Ambulance Service "a" in addition to telephone interview of S23, Vice President of Operations of Ambulance Service "a" revealed the call to Ambulance Service "a" was placed at 12:53:37, 48 minutes and 37 seconds after the physician (S9MD) ordered the patient transferred to the emergency room of Hospital "a" for evaluation. In addition, Cypress Psychiatric Hospital staff did not activate 911; they called the non-emergency transport line of Ambulance Service "a" . Review of the Medical record revealed that call lasted 3 minutes and 49 seconds ending at 12:57:26. The Ambulance Service dispatched the call electronically to the unit 37 seconds later (12:58:03). 2 minutes and 5 seconds later the unit electronically replied they were enroute to Cypress Psychiatric Hospital (13:00:08). 1 minute and 51 seconds later the unit electronically notified the Ambulance Service "a" Communications Center that they were at the hospital (13:01:59).

Review of the Medical Staff Rules and Regulations, last revised 06/18/11 and submitted by the hospital as the one currently in use, revealed..."Section 4. Emergency Services: 1. In the event of a medical emergency, the attending physician or physician or a member of the medical staff shall authorize and supervise the transfer of the patient to the nearest general Hospital in accordance with Standard Policy and Procedures..."

Review of Policy No: 639.1 titled "Medical Emergency" last revised 07/08 and submitted as the one currently in use, revealed..."Procedure: 6. When instructed by the physician, 911 will be activated...7. The nurse will continue to monitor the patient and ensure that physician orders are implemented until a higher level of medical help is available..."