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.

NORTH DAKOTA STATE HOSPITAL 2605 CIRCLE DRIVE JAMESTOWN, ND 58401 April 11, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review, the Hospital failed to ensure the plan of care included the use of a net blanket (a full body restraint for total immobilization) or a protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) and/or failed to include the contraindications for their use for 1 of 1 closed patient (Patient #11) record reviewed with a diagnoses of chronic obstructive pulmonary disease (COPD). Failure to identify the use of a net blanket or protective hood and the risks of their use on Patient #11's plan of care limited the Hospital staffs ability to manage the patient's behavioral issues.

Findings include:

Review of Patient #11's closed medical record occurred on all days of survey. The record identified the patient received care at the Hospital from 01/23/13 to 03/28/13. The medical record identified Hospital staff utilized a net blanket to restrain Patient #11 on 01/31/13, 02/07/13, and 03/28/13 and a protective hood on 03/28/13.

Patient #11's record lacked evidence the care plan included the net blanket or protective hood or the contraindications for their use.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on record review, review of Hospital policy and procedure, and staff interview, the Hospital failed to determine less restrictive interventions were ineffective before utilizing a net blanket (a full body restraint for total immobilization) for 1 of 1 closed patient (Patient #11) record reviewed who utilized this restraint. Failure of the Hospital staff to document the assessment process and the patients' response to less restrictive interventions prior to the net blanket violated Patient #11's rights and has the potential to violate the rights of all patients.

Findings include:

Review of the Hospital policy and procedure titled "SECLUSION and RESTRAINT" occurred on 04/09/13. This policy, dated October 2012, stated, "Alternatives to Seclusion and Restraint. Least Restricting Interventions: . . . Document all circumstances leading to the intervention, what intervention was used, and the outcome. This should be documented in the progress notes, (Form 331.) . . ."

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 01/31/13, identified the Hospital staff placed a net blanket on Patient #11 at 7:19 p.m. The form listed "Hands off Strategy" calming techniques (non-physical) used prior to the net blanket. The progress notes (Form 331), failed to identify the outcome to the hands off techniques and what, if any, less restrictive restraints attempted prior to the net blanket.

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 02/07/13, identified the Hospital staff placed a net blanket on Patient #11 at 3:35 p.m. after attempting "Hands off Strategies" and a waist and wrist restraint. The Hospital staff failed to document the events in the progress notes (Form 331).

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. The form listed "Hands off Strategy" calming techniques used prior to the net blanket. The progress notes (Form 331), failed to identify the outcome to the hands off techniques and what, if any, less restrictive restraints attempted prior to the net blanket.

During an interview on 04/10/13 at 7:55 a.m., an administrative staff member (#1) agreed Patient #11's medical record lacked documentation leading to the utilization of the net blanket.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on record review, review of Hospital policy and procedure, and staff interview, the Hospital failed to use the least restrictive form of interventions/restraints and document the patient's response before utilizing a net blanket (a full body restraint for total immobilization) for 1 of 1 closed patient (Patient #11) record reviewed who utilized this restraint and expired. Failure of the Hospital staff to attempt less restrictive interventions/restraints prior to the net blanket and document the interventions/restraints used or attempted and the outcome in the progress notes (Form 331) violated Patient #11's rights and has the potential to violate the rights of all patients.

Findings include:

Review of the Hospital policy titled "Restraint" occurred on 04/10/13. This undated policy stated, ". . . Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or a portion of the patient's body . . . (These can be mobile restraints, protective restraints, or total restraint). Definition of Terms: . . . Physical Intervention: NDSH [North Dakota State Hospital] approved nonviolent person to person restraint that is a part of the process of a more restrictive intervention such as preceding . . . net blanket or leather restraint. Person to person restraint is also used if necessary . . ."

Review of the Hospital policy and procedure titled "SECLUSION and RESTRAINT" occurred on 04/09/13. This policy, dated October 2012, stated, "Alternatives to Seclusion and Restraint. Least Restricting Interventions: Medical and Verbal. Rationale: To use the least restrictive method of diffusing a situation and helping a patient be calm. . . . Document all circumstances leading to the intervention, what intervention was used, and the outcome. This should be documented in the progress notes, (Form 331.) . . ."

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 01/31/13, identified the Hospital staff placed a net blanket on Patient #11 at 7:19 p.m. The form listed hands-off calming interventions used prior to the net blanket which included verbalizing, counseling, limit setting, reassurance, redirection, and offered oral medication. Review of the progress notes (Form 331), failed to identify the outcome to the hands-off interventions and what, if any, less restrictive restraints attempted prior to the net blanket.

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 02/07/13, identified the Hospital staff placed a net blanket on Patient #11 at 3:35 p.m. after attempting "Hands off Strategies" and a waist and wrist restraint. The Hospital staff failed to document the events in the progress notes (Form 331).

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. The form listed hands-off calming interventions used prior to the net blanket which included verbalizing, redirection, and change of environment. Review of the progress notes (Form 331), failed to identify the outcome to the hands-off interventions and what, if any, less restrictive restraints attempted prior to the net blanket.

During an interview on 04/10/13 at 7:55 a.m., an administrative staff member (#1) agreed Patient #11's medical record lacked documentation of less restrictive interventions attempted by the Hospital staff and their outcome before utilizing the net blanket.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, review of Hospital policy and procedure, and staff interview, the Hospital failed to protect and promote each patient's rights by failure to address the safety needs of the patients whose medical condition contraindicated the use of a net blanket (a full body restraint for total immobilization) and a protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) (Refer to A154); failed to determine less restrictive interventions before utilizing a net blanket (Refer to A164); failed to use the least restrictive form of interventions/restraints and document the patient's response (Refer to A165); failed to ensure the plan of care identified the use of a net blanket and protective hood and the risks of their use (Refer to A166); failed to follow Hospital policy related to the use of a net blanket (Refer to A167); and failed to obtain an order for a protective hood (Refer to A168). This placed all patients in serious and immediate jeopardy for harm. The survey team determined an Immediate Jeopardy situation existed on 04/10/13 at 11:50 a.m. At 12:10 p.m., the survey team notified an administrative nurse (#2) of the Immediate Jeopardy situation.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, review of hospital policy, review of manufacturer's guidelines, and staff interview, the Hospital failed to recognize the safe and appropriate use of a net blanket (a full body restraint for total immobilization) and protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) for 1 of 1 closed patient (Patient #11) record reviewed who utilized these restraints. Failure of the Hospital to ensure a patient's medical condition did not contraindicate the usage of a net blanket and protective hood violated the rights of Patient #11 and contributed to her death.

Findings include:

Review of the Hospital policy titled "Restraint" occurred on 04/09/13. This undated policy stated, "Rationale: The justification for restraint is for the need to intervene to save life or prevent injury. Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or a portion of the patient's body . . . Procedure: . . . 9) Vital signs should be checked initially (minimally pulse and respirations) and regularly thereafter (every 15 minutes at a minimum, if abnormal). . . ." (Refer to A395 for lack of vital signs)

Review of the Hospital policy and procedure titled "SECLUSION and RESTRAINT" occurred on 04/09/13. This policy, dated October 2012, stated, "Alternatives to Seclusion and Restraint. Least Restricting Interventions: Medical and Verbal. Rationale: To use the least restrictive method of diffusing a situation and helping a patient be calm. Interventions: 1. Non-provocation and recognition of patient needs. . . . 2. Medication . . . 3. Continuing verbal intervention. . . . 4. Environmental change. . . . Patient choice room/quiet time in a bed-room or other quiet room. . . . 6. Voluntary blanket wrap by request . . .7. If the previous interventions are exhausted then the next more restricting interventions are considered, which are: *Time out in room *Time out in Seclusion Room * Open Door Seclusion * Locked Seclusion Documentation: Document all circumstances leading to the intervention, what intervention was used, and the outcome. This should be documented in the progress notes, (Form 331.) . . ."

Review of the Hospital checklist titled "Net Blanket" occurred on 04/09/13. This document, dated November 2011, stated, ". . . Purpose: To be used on individuals assessed as being in extreme danger of injury to themselves or to others. Description: A full body restraint for total immobilization in a supine position. . . . CONTRADICTIONS TO THE NET BLANKET RESTRAINT: . . . COPD [chronic obstructive pulmonary disease]. ADVERSE REACTIONS: Severe emotional, psychological, and physical problems may occur . . . Individuals may become restless or agitated . . . WARNING: . . . Individuals in a supine position and unable to sit up require extra vigilance as they could have emesis, aspirate, and suffocate."

Review of the manufacturer's guidelines titled "Posey Restraint Net" occurred on 04/09/13. These guidelines, dated 2011, stated, ". . . BEFORE APPLYING ANY RESTRAINT: *Make a complete assessment of the patient to ensure restraint use is appropriate. *Identify the patient's symptoms . . . *Use the restraint only when all other options have failed. Use the least restrictive device, for the shortest time, until you find a less restrictive alternative. Patients have the right to be free from restraint. . . ."

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, "PURPOSE: To provide protection from a patient who is spitting and/or biting during restraint application. SCOPE: To be used ONLY on patients with a history of multiple incidents of spitting and/or biting during restraint application or a patient who is actually spitting while being restrained. CONTRAINDICATIONS: Do not use the protective hood on any patient who is vomiting, having difficulty breathing . . . D. Remove the hood as soon as the restraints have been applied. . . ."

- Review of Patient #11's closed medical record occurred on all days of survey. The record identified an admission date of [DATE]. diagnoses included [DIAGNOSES REDACTED]#11 on 01/31/13, 02/07/13, and 03/28/13 and a protective hood on 03/28/13.

Patient #11's "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 01/31/13, identified the behaviors leading up to the net blanket as, "Pt. [patient] was in the hallway striking out at staff, kicking staff, and biting staff. She was tearing her clothes off and staff's clothes off." Alternative methods attempted prior to the net blanket included verbalizing, counseling, limit setting, reassurance, and offered oral medication. The form identified Patient #11 received an injection of Ativan (an antianxiety medication), Benadryl (an antihistamine used for sedation), and Haldol (an antipsychotic) at 7:12 p.m. The form identified the patient's respirations as "labored" but failed to document her respiration rate, pulse, or blood pressure.

The "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 01/31/13, utilized by Hospital staff to document the patient's activity during seclusion or restraint use, identified at 7:07 p.m. Hospital staff placed Patient #11 on gurney with chest straps and transported her to the L100 wing, transferred her onto a bed, and placed her in a net blanket at 7:12 p.m. The Hospital staff removed the net blanket at 9:13 p.m.

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 02/07/13, identified Patient #11's behaviors leading up to the net blanket as, "Behavior has been escalating all morning. Not accepting redirection, PRN [as needed] medications given . . . not effective . . . bang head on wall, biting at staff . . ." Hospital staff placed Patient #11 in waist and wrist restraints at 11:45 a.m., removed them at 3:15 p.m., and placed a net blanket on the patient at 3:25 p.m.

Review of Patient #11's "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 03/28/13, identified the behaviors leading up to the net blanket as, "Spitting, screaming, banging head." Alternative interventions attempted prior to the use of the net blanket included redirection and change of environment. The form identified the patient's respirations as "labored" but failed to document her respiration rate, pulse, or blood pressure. The Hospital staff applied the net blanket at 9:23 p.m.

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed Patient #11 in the net blanket at 9:23 p.m. At 9:32 p.m., staff placed a mask on the patient. Patient #11 stopped breathing at 9:35 p.m. and the the staff removed the net blanket. Hospital staff announced "Code Blue," a medical emergency situation, at 9:45 p.m.

Review of Patient #11's progress notes (Form 331), dated 01/31/13, 02/07/13, and 03/28/13, failed to identify Patient #11's response to the calming interventions attempted by Hospital staff and failed to identify less restrictive physical interventions attempted before the net blanket.

The Hospital staff utilized the net blanket restraint and protective hood even though the Patient #11's medical condition, facility policy, and manufacturer guidelines contraindicated its use.

During an interview on 04/10/13 at 7:55 a.m., an administrative staff member (#1) confirmed a net blanket is contraindicated for patients with a diagnoses of [DIAGNOSES REDACTED]
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on record review and review of Hospital policy, the Hospital failed to follow their policy related to the use of a net blanket (a full body restraint for total immobilization) and protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) for 1 of 1 closed patient (Patient #11) record reviewed. Failure to follow Hospital policy violated Patient #11's rights and contributed to her emergent care and subsequent death.

Findings include:

Review of the Hospital checklist titled "Net Blanket" occurred on 04/09/13. This document, dated November 2011, stated, ". . . Description: A full body restraint for total immobilization in a supine position. . . . CONTRADICTIONS TO THE NET BLANKET RESTRAINT: . . . COPD [chronic obstructive pulmonary disease] . . . WARNING: . . . Individuals in a supine position and unable to sit up require extra vigilance as they could have emesis, aspirate, and suffocate."

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, "PURPOSE: To provide protection from a patient who is spitting and/or biting during restraint application. . . . CONTRAINDICATIONS: Do not use the protective hood on any patient who . . . having difficulty breathing . . . D. Remove the hood as soon as the restraints have been applied. . . ."

Review of Patient #11's closed medical record occurred on all days of survey. Diagnoses included COPD. The medical record identified the Hospital staff used a net blanket to restrain Patient #11 on 01/31/13, 02/07/13, and 03/28/13 and a protective hood on 03/28/13.

Patient #11's progress notes (Form 331), dated 03/28/13 at 6:50 a.m., stated, "Pt [patient] rested good up until 0500 [5:00 a.m.] then was awake, restless in bed, . . . coughing spell noted . . . pt sat up et [and] was encouraged to deep breath . . ." (Refer to A395)

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. and a "mask" (protective hood) on patient at 9:32 p.m. Patient #11 stopped breathing at 9:35 p.m. The nurse practitioner's progress notes (Form 331), dated 03/28/13 at 11:00 p.m., stated. ". . . staff called this writer @ 9:35 p.m. that pt was having difficulty breathing. . . ." (Refer to A395)

The Hospital failed to follow their policy and placed a net blanket and protective hood on Patient #11 even though her medical condition contraindicated their use.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review, review of Hospital policy, and staff interview, the Hospital failed to obtain an order for the placement of a protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) from the Independent Licensed Practitioner (ILP) for 1 of 1 closed patient (Patient #11) record reviewed who utilized a protective hood. Failure to obtain an order does not give the ILP the opportunity to choose a less restrictive form of protection and violated the rights of this patient.

Findings include:

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, ". . . Procedure: A. Licensed staff obtain an order from the Independent Licensed Practitioner for the application of the protective hood . . ."

Review of Patient #11's medical record occurred on all days of survey. Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed a "mask" on Patient #11 at 9:32 p.m. without obtaining an order from the ILP.

During an interview on 04/10/13 at 8:10 a.m., an administrative nurse (#2) confirmed the Hospital staff failed to obtain an order from the ILP before the utilization of the protective hood.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review, review of Hospital policy and procedure, review of professional reference, and staff interview, the Hospital failed to ensure supervision of nursing services by not administering oxygen and medication to patients in a safe and timely manner (Refer to A395 and A405); and failed to obtain the vital signs for patients prior to the use of restraints (Refer to A395). This placed these and future patients in serious and immediate jeopardy for harm. The survey team determined an Immediate Jeopardy situation existed on 04/10/13 at 11:50 a.m. At 12:10 p.m., the survey team notified an administrative nurse (#2) of the Immediate Jeopardy situation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, policy and procedure review, and staff interview, the Hospital failed to administer oxygen for 1 of 1 closed patient (Patient #11) record reviewed for low oxygen saturation; and failed to obtain vital signs prior to the initiation of restraints for 6 of 6 active patient restraint records reviewed (Patient #1, #4, #5, #6, #7, and #8) and 3 of 5 closed patient restraint records reviewed (Patient #11, #12, and #13). Failure to ensure Patient #11 received oxygen during respiratory distress and failure to obtain vital signs prior to the use of restraints contributed to the death of Patient #11 and placed all patients at a safety risk.

Findings include:

Review of the Hospital policy titled "Oximeter Guidelines For Use" occurred on 04/10/13. This policy, dated March 2013, stated, "PURPOSE: To determine the oxygen saturation . . . Sudden Changes: If there is a sudden change in which the O2 [oxygen] drops below 90% [percent], call the Medical LIP [Licensed Independent Practitioner] to evaluate the individual. . . . Licensed nurses may start oxygen at 1 -2 liters . . . If the O2 level is below 80%, this is life threatening and considered an emergency. Call the Medical LIP immediately . . ."

Review of the Hospital policy titled "Restraint" occurred on 04/10/13. This undated policy stated, ". . . Procedure: Emergency Restraint Orders . . . 9) Vital signs should be checked initially (Minimally pulse and respirations) and regularly thereafter (every 15 minutes at a minimum, if abnormal). . . ."

- Review of Patient #11's medical record occurred on all days of survey. Medical diagnoses included chronic obstructive pulmonary disease (COPD). A treatment order, dated 02/14/13, "Oxygen . . . PRN [as needed] [for] O2 [oxygen] Sat [saturation [less than] 90 [percent/%] . . ."

Patient #11's progress notes (Form 331), dated 03/28/13 at 6:50 a.m., stated, "Pt [patient] rested good up until [5:00 a.m.] then was awake, restless in bed, . . . coughing spell noted. O2 sat check @ [at] [5:10 a.m.] et [and] was 78 - 79%. pt sat up et was encouraged to deep breath et O2 sat [increased] to 92% on RA [room air]. Pt settled some et was able to rest until [6:30 a.m.] . . . et AM Neb tx's [nebulizer treatments] were administered . . ."

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. and a "mask" (protective hood) on patient at 9:32 p.m. Patient #11 stopped breathing at 9:35 p.m. The nurse practitioner's progress notes (Form 331), dated 03/28/13 at 11:00 p.m., stated. ". . . staff called this writer @ 9:35 p.m. that pt was having difficulty breathing. She was sitting up breathing when this writer arrived but staff stated she had stopped breathing briefly just before this. O2 sats were poor 40 - 50 [%] . . ." The "Code Blue (an emergency situation) Flow Sheet," dated 03/28/13, identified the Hospital staff administered oxygen at 9:51 p.m., 16 minutes after Patient experienced breathing difficulties.

During an interview on 04/10/13 at 8:10 a.m., an administrative nurse (#2) stated she would expect Hospital staff to administer oxygen to a patient with low oxygen saturation.

The Hospital staff failed to administer oxygen to Patient #11 on 03/28/13 5:10 a.m. when her oxygen saturation dropped to 78% and failed to administer oxygen again at 9:35 p.m. when she experienced breathing difficulties.

- For each of the following episodes of restraint use, the patients' records lacked evidence staff obtained vital signs prior to initiation of the restraints:
* Patient #1: Four point restraints on 01/02/13, 01/06/13, and 01/26/13 and net blanket restraint on 01/03/13
* Patient #4: Four point restraints on 01/09/13 (twice), 02/01/13 (twice), 02/02/03, and 02/08/13 and a net blanket on 02/01/13, 02/02/13, 02/08/13, and 03/26/13
* Patient #5: Four point restraints on 01/11/13
* Patient #6: Four point restraints on 02/22/13, 02/27/13, and 03/20/13
* Patient #7: Four point restraints on 01/02/13 and 01/16/13
* Patient #8: Four point restraints on 01/01/13 and waist/wrist restraints on 02/12/13, 02/13/13, 02/14/13, 02/15/13, 02/16/13, 02/17/13, 02/21/13, 02/22/13, and 03/08/13
* Patient #11: Net blanket on 01/31/13 and 03/28/13
* Patient #12: Four point restraints on 02/09/13 and 02/15/13
* Patient #13: Four point restraints on 01/23/13 and 01/25/13
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and review of professional reference, the Hospital failed to ensure nursing staff administered medications in a safe manner for 1 of 1 closed patient (Patient #11) record reviewed in a net blanket (a full body restraint for total immobilization) and in a supine position. Failure to position Patient #11 in an upright position before administering an oral medical contributed to her death.

Findings include:

Kozier and Erb's, Fundamentals of Nursing Concepts, Process, and Practice, ninth ed., 2012, page 869, stated related to medication administration, ". . . Assist the client to a sitting position or, if not possible, to a side-lying position. Rationale; These positions facilitate swallowing and prevent aspiration. . . ."

Review of Patient #11's medical record occurred on all days of survey. The treatment orders identified a pureed diet, pudding thickened liquids, and to keep the patient upright for 30 minutes after meals.

The "Seclusion/Restraint for Behaviors" flow sheet identified the Hospital staff placed Patient #11 in a net blanket (a full body restraint for total immobilization in the supine position) at 9:23 p.m. At 9:28 p.m., the patient received Chlorpromazine 50 milligrams orally (an antipsychotic medication). At 9:30 p.m., the flow sheet stated "spitting, yelling" and at 9:32 p.m., the Hospital staff placed a "mask" on the Patient #11's face. A mask, also known as a protective hood, provides protection from a patient who is spitting and/or biting. At 9:35 p.m., Patient #11 stopped breathing. An ambulance arrived at 10:05 p.m. and transferred the patient to a medical hospital where she expired.

The facility's failure to administer oral medications in an appropriate manner contributed to Patient #11's death.