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.

TWO RIVERS BEHAVIORAL HEALTH SYSTEM 5121 RAYTOWN ROAD KANSAS CITY, MO 64133 March 18, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observations, interviews, record review and policy review, the facility failed to:
- restrict potentially hazardous devices from patients;
-failed to monitor patients;
-failed to provide life saving interventions.
Due to the severity of the situation and the potential harm to all patients, this resulted in overall noncompliance with the 42 CFR 482.13 Condition of Participation: Patient's Rights and demonstrates an unsafe patient care environment. This situation constitutes a condition of unabated Immediate Jeopardy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on policy review, observation, interview, record review and review of facility policies, the facility failed to ensure patients admitted with suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting (staffed, designed and equipped to minimize the patient's ability to harm themselves or others) for one (#4) of nine patients on suicide precautions.
The facility census was 59.
Findings included:
1. Record review of the facility's policy titled, "Patient Observation Policy," dated 09/17/10, showed the following direction:
- Perform rounds in varying patterns or sequences throughout the units to minimize planned acting out opportunities;
-Observe patients on bed rest or when sleeping by looking for the rise and fall of the chest and counting at least three respirations, and/or making sure that the patient has moved from his/her previous sleeping position.

Record review of the facility's policy titled, "Precautions" , dated 11/18/10, showed the definition for Suicide Precautions (SP): All patients who verbalize suicidal ideation with/or without plan and/or intent or have attempted suicide or self-injury will be considered in imminent danger and will be placed on Suicide Precautions. Patients on Suicide Precaution will be carefully monitored and assessed every 15 minutes to minimize the potential for self harm. Shoelaces, belts and other potentially dangerous items will be removed from the patient's possession.

Record review of the facility's policy titled, "Patient observation", dated 05/04/10, showed the following definition: 1:1 observation, purpose: to provide safe care for any patient who is exhibiting highly dangerous behaviors or is deemed highly dangerous to self and/or others.

Record review of the facility's policy titled, "Code Blue (Cardiac Arrest)", dated 08/06/09, showed: the first responder will begin the ABC's (Airway, Breathing and Circulation) of CPR (Cardio-Pulmonary Respiration) on a non-responsive patient. If no sign of breathing, two breaths are given with an emergency resuscitation bag.

2. Record review of deceased patient #4 ' s medical record showed he/she was admitted on [DATE] for depressive disorder with psychosis, generalized anxiety disorder, and borderline personality disorder.

Review of the patient's Admission Inquiry Sheet, dated 03/09/11, showed the patient had gone out with the ex-spouse for an outing from the nursing home and asked the ex-spouse to leave the patient in the woods to die.

Review of the Assessment Form dated 03/09/11, showed the patient has current suicidal ideations, current plan for suicide, a history of depression, aggressive behavior, hallucinations, delusional and paranoid thoughts. Staff assessed the patient as a danger to self.

Review of the admission orders dated 03/09/11 showed the physician placed patient on suicide precautions.

Review of the History and Physical dictated on 03/10/11 showed to monitor for apparent suicidal ideations, although he/she appears aware that it would not be in his/her best interest to acknowledge any suicide ideation he/she may be experiencing.

Review of nursing progress notes dated 03/11/11 at 06:48 PM showed documentation the patient was very agitated, hitting the walls in the bathroom, and then laid on bathroom floor. Patient's affect was flat. There was no documentation that the physician was notified of patient's behavior and agitation. Nor was the patient placed on 1:1 monitoring as indicated in facility policy.

Review of nursing progress notes dated 03/12/11 at 06:23 AM, showed Staff E R. N. (Registered Nurse), documented: at approximately 05:24 AM, this nurse responded to tech being unable to do/obtain vital signs. Found patient unresponsive to verbal and external stimuli. Code called and CPR began. 911 called and CPR continued until emergency personnel took over the code.

3. Review of a hall video from Module C, the Geriatric Unit, with Staff A, Chief Executive Officer and Staff B, Director of Nursing, for 03/12/11 showed the facility failed to monitor patient #4 every 15 minutes for SP at the following times:
-12:15 AM - 12:39 AM showed a 24 minute gap without monitoring;
-1:53 AM - 2:16 AM showed a 23 minute gap without monitoring;
-2:44 AM - 3:05 AM showed a 21 minute gap without monitoring;
-3:22 AM - 3:42 AM showed a 20 minute gap without monitoring;
-3:55 AM - 4:26 AM showed a 31 minute gap without monitoring;
-4:26 AM - 4:50 AM showed a 24 minute gap without monitoring;
-4:50 AM - 5:15 AM showed a 25 minute gap without monitoring.

Review of hall video on Module C for 03/12/11 showed staff making patient rounds. Staff followed the same predictable pattern and did not vary the rounding pattern.

-5:15 AM - showed Staff F, Mental Health Technician (MHT), entered patient #4's room;
-5:20 AM - showed Staff F exited room and walked casually to the nurse's station and began talking to Staff E, R.N.;
-5:21 AM - Staff E, D (R.N.) entered patient's room;
-5:22 AM - Staff D exited room and is observed on the phone and Staff F exited room, and E entered hallway and returned to room;
-5:23 AM - Staff D was seen struggling to carry a code bag (resuscitation equipment, including an oxygen tank), dropped the bag to the floor and dragged the bag to the patient's room. Staff D exited the room. Staff F, MHT remained standing in the hallway;
-5:23 AM -5:25 AM showed nursing Staff E, D, K, M, G, H and I (6 R.N.s) and one MHT entering and exiting the room;
-5:26 AM Staff D, R.N. ran out of the room and obtained an additional oxygen tank;
-5:29 AM Staff I, R.N. escorted patient #4 ' s roommate out of the room;
-5:31 AM Paramedics arrived;
-5:32 AM Staff G placed items from patient #4's room on the counter of the nurse's station;
-7:12 AM Patient #4's attending physician arrived on Module C;
-7:20 AM the Medical Examiner arrived on Module C.

4. During an interview on 3/15/11 at approximately 3:00 PM Staff A, Chief Executive Officer stated that since Patient #4's death, as of 3/14/11 a new policy had been instituted requiring items from the sensory items be checked in and out by patients. Staff A stated prior to Patient #4's death, there was no requirement that these items be accounted for at all times.

During an interview on 03/17/11 at 8:35 AM Staff D, RN for Module C stated that he/she did not believe Patient #4 got his/her medications on 03/11/11 and the patient was banging his/her head against the wall. Staff D stated that when the MHT, Staff F was on break on 03/12/11 at around 4:30 AM or 4:45 AM, he/she made rounds. Staff D stated the patient was in bed with the covers up to his/her neck. Staff D did not remember if patient #4 was breathing or not.

During an interview on 03/17/11 at 9:07 AM, Staff E, R.N. on Module C stated that Staff F, MHT came to the desk and stated patient #4 didn't stick up his/her arm for the blood pressure (B/P) check like he/she normally did when calling his/her name. Staff E stated that Staff F, MHT, never said the patient was not breathing or without a pulse. Staff E stated, too much time passed before he/she checked on patient #4. If he/she had known patient #4 was not breathing or without a pulse, he/she would have immediately called a Code Blue (medical emergency response to cardiac respiratory failure). Staff E found patient #4 in the patient ' s room with no pulse or respiration and started CPR. Another staff member (Staff G) came to the room and bagged (use of an Ambu bag connected to oxygen to ventilate the patient by squeezing on the Ambu bag) the patient and found things wrapped around the patient ' s neck. Staff E stated that Staff G cut items from around the patient ' s neck.

During an interview on 03/17/11 at 9:42 AM, Staff G, R.N. from Module B, stated that when he/she responded to the Code Blue, he/she found Staff E, R.N., doing compressions for patient #4. Staff D, R.N. was standing at the feet of patient #4, doing nothing, except nudging at the feet of patient #4 saying "wake-up, wake-up" . Staff G stated that there was nothing going on for ventilation for patient #4. Staff G got an oxygen mask and tubing out of the code bag to administer oxygen and he/she tilted patient #4 's head back to put the mask on, and noticed a green rubber thing around the patient's neck. Staff G said, "What is this?" The green rubber thing was tight. Staff G put his/her hands under the green thing and broke it. It looked like the patient twisted it in the front to tighten it. Staff G said then he/she noticed a black nylon strap around the patient's neck. Staff G stated that he/she could not believe the patient had this kind of stuff in his/her room. The black item was like a strap with a plastic buckle where you put the other end through the buckle and bring it back over and push down on the hook and loop (therapeutic wrist support device, black hook and loop band). The strap was about 2 inches wide and about 10-11 inches long; it was really tight. I was able to get my hands under it to lift it up so Staff K, R.N., could cut the ligature. The black strap had a white ribbon on the buckle. It took a minute to get everything off the patient's neck so the patient could be ventilated.
The Code had been going on for a few minutes before Staff G arrived so he/she didn't think the oxygen would do any good. The Automated External Defibrillator (AED a computerized medical device which can check a person's heart rhythm and deliver electric shocks if needed) indicated no shock was recommended, so he/she knew there was no heart rhythm. The patient ' s color was mottled (areas of purple and pale areas which indicates extremely poor to no oxygenation) and grayish. Staff G stated the patient did not look like somebody that was going to be revived. Staff G stated that current CPR training tilting the patient's head back to open the airway and he/she couldn't believe no one had found the ligatures around the patient's neck.

Review of facility photo documentation, taken on 3/15/11, of two items removed from Patient #4's neck included a black nylon strap used as part of a supportive device, and a toy obtained at the facility. The photo showed the toy to be a bright neon green flexible stretchy toy made of soft plastic rubber or silicone ring for therapeutic sensory touch that can be twisted and squeezed for tactile stimulation.

During an interview on 03/17/11 at 10:32 AM, Staff F stated that his/her duties included patient vital signs, watching the rise and fall of a patient's chest to check for breathing during rounds every 15 minutes. Patient #4 was lying in bed on her side facing the window with covers up to his/her neck. When doing the vital signs at 5:00 AM, he/she took the roommate's vital signs then went to take patient #4's vital signs. Patient #4 did not respond. Patient ' s eyes were closed. He/she thought the patient was asleep. Staff F stated he/she did not check for respirations. Patient #4 was lying in bed on the side facing the window with covers up to the neck. Every time he/she checked, the patient would be in this same position. The covers prevented the ability to check for respirations. Staff F stated he/she had noticed a toy-like item (a circular, rubbery-type toy that was about seven inches in diameter in the shape of a circle that was stretchy, approximately 1.5 inches thick) on the patient's arm earlier in the day, but not while checking the patient on rounds.

During an interview on 03/17/11 at 10:55 AM, Staff H, R.N. House Supervisor, stated that when he/she responded to the code staff in the room were not bagging the patient, not doing ventilation and had not applied an oxygen mask to the patient.

During an interview on 03/18/11 at 9:20 AM, Staff AA, the patient's attending physician, stated that staff did not notify him/her that the patient refused to take his/her AM medications, that he/she was upset and agitated, and that he/she was hitting the wall on 3/11/11. The physician stated that the facility should inform the physician when the patient is harmful to self or others. The physician stated that if the facility had informed him/her of the patient's behaviors, he/she would have ordered medication. The physician stated that the therapeutic wrist support device (black hook and loop band) was for the patient's Carpel Tunnel Syndrome (nerve constriction) and stated that he/she didn't think anything about the patient having it if it made the patient more comfortable. The physician stated that he/she had not seen the ribbon on the black wrist support. The physician stated it was not good for the patient to have the green toy unless the patient was in group and could be observed.