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.

BEHAVIORAL HOSPITAL OF LONGVIEW 22 BERMUDA LANE LONGVIEW, TX March 1, 2016
VIOLATION: NURSING SERVICES Tag No: A0385
Based upon observation, record review and interview, the facility failed to
follow their own policy and procedure for Opioid Detoxification. The nursing staff failed to assess and monitor 1 (#1) of 10 (1-10) patients that was admitted for Opioid Detoxification, failed to notify the physician when patient experienced a change in condition, and failed to ensure a Registered Nurse (RN) was available at all times to supervise staff and monitor the needs of the patients. This deficient practice resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.


Refer to Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon record review and interview, the nursing staff failed to assess and monitor 1 (#1) of 10 (1-10) patients that was admitted for Opioid Detoxification, failed to notify the physician when patient experienced a change in condition, and failed to ensure a Registered Nurse (RN) was available at all times to supervise staff and monitor the needs of the patients. This deficient practice resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.

Review of patient #1's chart revealed the patient was admitted voluntarily for Opioid Detox on 2/24/16 at 10:58AM.

The patient was seen by the admissions nurse for a pre-screening assessment on 2/24/16 at 9:17AM. Review of the RN pre-screening assessment revealed patient #1 was a 5'4", 160lb, [AGE] year old white female. Patient #1 was documented as disheveled appearance, slurred speech, intoxicated, anxious, and lethargic. Patient had a history of [DIAGNOSES REDACTED], arthritis and gastric bypass. The vital signs were Temperature 99.1, Pulse 104 (elevated), Blood Pressure 82/64(low), Oxygen Saturation 97% on room air, pain level 9/10 (1 being no pain and 10 being the worst pain.)

The following medications were documented as patient #1's home medications:

1. Trazadone (is a tetracyclic antidepressant used to treat depression and anxiety disorders) 300mg every evening.
2. Xanax (benzodiazepine for anxiety) 2mg three times a day.
3. Xanax orally disintegrating tablets (ODT) (benzodiazepine for anxiety) 1 mg twice a day as needed.
4. Restoril (benzodiazepines is used to treat insomnia symptoms) 30mg every evening.
5. Flexeril (a muscle relaxant) 10mg twice a day as needed.
6. Torsemide (is a diuretic) 5 mg as needed.
7. Zyprexa (is an antipsychotic medication that affects chemicals in the brain) 25mg daily.
8. Klonopin (benzodiazepines is used to treat seizure disorders or panic disorder) 1mg twice a day.
9. Zubsolv (prescribed for treatment of Opioid Dependence) 8.6/2.1 subling 1 daily.

Review of the RN pre-screening assessment under the " Behavioral Description of the Presenting Problem " stated, " Addicted Xanax-using + 5 yrs. Rx 2mg QID, was on Norco " long time " still using doesn ' t remember last dose. On Zubsolv for 2 yrs 8.6/2.1 mg subling 1 daily- last today. Increased mdd, crying spells, increased falling, fall asleep at desk, poor sleep at night. " The nurse documented in this description the Xanax was prescribed QID (4 x a day) but documented on the medication list that the Xanax was prescribed TID (3 times a day.) Further review of the assessment revealed, "Patient #1's last dose of Xanax was 2/23/16 and used the drug daily."

Review of the RN pre-screening assessment under the "Types of Substance used" revealed the nurse documented, "Patient #1's last dose of Xanax was 2/23/16 and used the drug daily." There was no dosage documented or how often.

Review of the "pre-admission exam & certification" sheet dated 2/24/16 at 10:58AM revealed patient #1 was seen by a physician utilizing telecommunication.
(The facility had a contract with medical doctors (MD) to perform medical evaluations through a tele-monitoring system on patients admitting to the facility The MD appears on a monitor screen and interviews the patient. The patient can interact back with the physician. The physician relies on the admission nurse for a hands on approach, to observe the patient, take vital signs, inspect the patient's body, and monitor the surroundings as necessary.)

Review of the "pre-admission exam & certification" sheet dated 2/24/16 at 10:58AM revealed patient #1 was seen by a MD using Telemedicine. The MD documented on 2/24/16 at 10:58AM, "Per MD: 54y/o pt. presents with substance abuse. Using Xanax 4mg daily, last was 2-4 days ago. Zubsolv 8.6/2/1 daily, last was last night. C/o withdrawal SX. Slow response. drowsy. " Mental Status Exam section of the doctors exam revealed patient #1 was cooperative, rambling, slow, judgement poor, insight fair, reliability poor, thought psychotic, no suicidal or homicidal ideation.

Review of the admitting physician orders dated 2/24/16 at 10:58AM revealed the following medications were ordered for patient #1:
1. Flexeril 10mg by mouth twice a day as needed for pain.
2. Restoril 30mg by mouth every evening as needed for sleep.
3. Torsemide 5mg by mouth daily as needed for edema.
4. Trazodone 300mg by mouth every evening for sleep.
5. Zyprexa 2.5mg by mouth daily for mood.
6. Zubsolv 8.6/2.1mg was discontinued.

Review of the admitting physician orders for patient #1, dated 2/24/16 at 10:58AM, revealed the following:
1. "Opiate detox protocol"

Review of the policy and procedure "Detoxification from Opiates-General III Nursing Assessment 2.The nurse will contact the psychiatrist to provide a verbal report of the patient's assessment and obtain the Physicians Admission Orders specific to the detoxification as per the patient diagnosis and history."

The initial physician orders were from the telemedicine MD. The MD orders stated to call the "Inpatient psychiatric unit, notifying physician for admission." There was no found documentation that the attending physician was notified.


2. The orders stated, "Labs: CBC with diff/plts, Comprehensive Metabolic Profile, TSH, Liver Panel, UDS, RPR, Lipid Panel, Urine Pregnancy, UA." There was no evidence that any labs were performed.

An interview with staff #3 on 2/29/16 revealed labs are not generally taken upon admission. All labs are collected the following morning. Staff #2 and #3 confirmed patients were treated and administered medications without having initial lab work done to determine any underlying medical issues.

3. Under profile section the physician had marked "no" for pregnancy. Review of the chart revealed there was no documentation of a pregnancy test administered.

Review of the Nursing pre-screening assessment on 2/24/16 at 9:17AM revealed under the "OB-GYN" revealed patient#1 had not had a period in 2 weeks.There was no documentation of a tubal ligation or hysterectomy.

4. Opiate Detox Protocol:

Clonidine 0.1 mg by mouth every 4 hours, hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60.
Dicyclomine 20mg by mouth every 6 hours prn if cramping.
Ibuprofen 600mg by mouth every 6 hours prn if pain or headache.
Methocarbamol 500mg by mouth every 6 hours prn if muscle pain.
Lorazepam 2 mg by mouth every four hours prn agitation. Do not exceed 10mg in 24 hours.

Review of the patient #1's chart revealed the patient's blood pressure was 102/58 at 12:45PM, 105/68 at 4:45PM and 164/77 at 8:45PM. There was no further vital signs documented after 8:45 PM on 2/24/16. There was no documentation that patient #1 received Clonidine or if it was held.

Review of a "PRN Assessment and Narrative" sheet revealed staff #9 administered Tylenol 650mg to patient #1 on 2/24/16 at 5:15PM for a pain scale of 8/10 for lower back pain and was reassessed at 6:15PM "pt asleep." Review of the patient Medication Assessment record (MAR) revealed patient #1 was administered Ibuprofen 600 mg by mouth at 5:15PM not Tylenol. There was no documentation on the MAR that Tylenol was given.

Review of a "PRN Assessment and Narrative" sheet revealed staff #10 administered Trazadone 300mg at 8:30PM due to insomnia and anxiety. Staff #10 documented on 2/24/16 at 9:30PM that patient #1 "was in bed asleep. Respirations even and unlabored. No further complaints of insomnia medication effective." Review of the Mental Health Technicians "q15 minute observation" sheet revealed patient #1 was in the bathroom, not asleep, at 9:30PM.

Review of the MAR revealed on 2/24/16 at 9:00PM patient #1 was administered Ibuprofen 600mg for a second time. The order says every 6 hours as needed. Last dose administered at 5:15PM a difference of 3 hours and 45 minutes. There was no found documentation on why patient #1 was administered the Ibuprofen or if the patient was reassessed.

Review of the MAR revealed on 2/24/16 at 9:00PM patient #1 was administered Methocarbamol 500mg by mouth. There was no found documentation on why patient #1 was administered the medication or the effects of the medication.

5. The physician orders under vital signs stated, "Detox: q4 hours x 24hours then q shift if stable. Notify MD for Systolic blood pressure greater than 160 or less than 90; Diastolic blood pressure greater than 90 or less than 50; Heart rate greater than 12 or less than 60; Temperature greater than 101 or lower than 95.
Review of patient #1 ' s chart revealed an Opioid Detoxification Flowsheet. Patient #1 was assessed and vital signs were taken on 2/24/16 at 12:45PM, 4:45PM and 8:45PM. Review of the flowsheet revealed at 8:45 PM, patient had a blood pressure of 164/77. There was no evidence in the medical record that the attending physician was notified of the elevated blood pressure. There were no further assessments or vital signs found after 8:45PM
Review of patient #1's chart revealed staff #8 (RN) gave report to staff #11(RN) on 2/24/16 at 11:00PM. The following nursing entries were found for patient #1 from 11:00PM -5:50AM on 2/24-2/25/2016:
11:36 PM staff #11 documented, "pt. is in bed sleeping response to noise. Respirations even and unlabored. No acute distress noted at this time. Unable to complete nursing assessment at this time. Will continue to monitor." There was no documentation found explaining why the nurse was unable to assess the patient.
1:30AM staff #11 documented, "Pt. in bed with eyes closed, respirations even and unlabored, breathing normally with rise and fall of chest noted. No acute distress noted. Will continue to monitor."
3:30AM staff #11 documented, "Pt. in bathroom, came back to bed. No acute distress noted. Pt. in bed, breathing normally respirations even and unlabored. No acute distress noted at this time will continue to monitor."
5:00AM staff#11 documented, "Pt. in bed with no distress. Respirations even and unlabored. Rise and fall of Pts. chest noted for normal breathing. Will continue to monitor."
5:50AM staff #11 documented, "Pt. is in bed, this nurse asked Pt. if she would be going to breakfast, no response. Noted pt. is not breathing and unresponsive. Called for help started CPR after placing pt. on the floor. Asked someone to call 911. Compressions given 30 and 2 breaths by mouth. Pt. had a pulse but faint. Compressions continued, gave two breaths, weak pulse, no pulse noted. Continue compressions AED applied on pt. Staff #10 continued CPR. This nurse called the DON on my cell phone, ambu bag being used at this time by staff #14. CPR continued till EMS arrived and took over. Pt. is put on a stretcher. A few minutes later EMS said no vital signs. EMS notified police. Administration notified at 6:14AM, physician notified. Detectives were called by police officers. Information requested by him was provided. Approximately 8:30AM, JP arrived. Family was notified by DON. DON with family at bedside. Body will be released to Lakeside Funeral Home. Belongings released to family per House Supervisor staff #6."

Review of the Cardiopulmonary Resuscitation Flow Sheet revealed the following;

1. CPR was initiated at 5:50AM on 2/25/16.
2. 5:55PM EMS called. There was no found documentation on why it took five minutes to call EMS.
3. The AED (automated external defibrillator) sheets revealed patient #1was in Asystole when the AED was placed on patient#1 at 6:06AM (16 minutes later). There was no documentation found on delay.
(Asystole known as flat line, is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow.)
4. 6:10AM EMS arrived and took over.
5. EMS called the code at 6:14AM.

There was no documented information on what personnel attended the code or what the duties were of that personnel. The signature and discipline on the CPR flow sheet in not legible.

Review of the EMS Report revealed the 911 call was received and dispatched at 5:55AM. The EMS was in route at 5:56AM and at scene at 6:03AM. EMS reached patient #1 at 6:05AM on 2/25/16. EMS documented, "Arrive on scene to find pt. lying in the floor unresponsive with staff doing CPR, Pt has mottled skin (varied patches of color) and cyanosis (blue) around the mouth. Pt has Rigor Mortis in the hands and in the jaw. CPR efforts are withheld at this point." (Rigor mortis is one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Rigor mortis occurs three to four hours after death.)

Review of the incident report revealed the date of the incident was 2/25/16 at 5:50AM on unit 4 room 409B. Patient #1 was involved and staff #11. The incident checked was "medical problem/911." Review of the second page of the incident report has "incident report" marked through with a pen and written in was "employee statement." A written statement was made with no signature of person making the statement. The "actions taken" section was left blank. The signature line for "report completed by" and time was left blank. The employee written statement revealed the patient went to the cafeteria to eat at 4:15pm and returned to the unit at 6:30PM. "I announced about going to A.A. and she replied yes she wanted to attend then I got her q 15 min observation sheet and went back down the hallway to ask other patients and she stopped me in the dayroom and asked what it was I said. I told her and she said she thought I asked if she wanted an egg. I replied no mam and then she wanted me to take her back to her room and then that's when med nurse took her to her room and after then that's when I took the other patients to A.A."

Review of the MHT Q15 minute observation sheets revealed Patient #1 was documented attending an A.A. meeting from 6:45PM until 7:45PM. There was no clear documentation on where patient #1 was during this time frame.
An interview was conducted with staff #3 (Risk Manager) on 2/29/16. Staff #3 reported she arrived at the facility after the code on 2/25/16. Staff #3 reported that review of the chart revealed Staff #11 had not written her nurses notes for Pt. #1 for the shift. Staff #3 stated Staff #11 wrote the shift notes after the incident.
An interview was conducted with staff #6 and staff #12 on 2/29/16. Staff #6 reported that staff #11 was assigned as the house supervisor on the night shift of 2/24-2/25/2016. The charge nurse called in and left the RN charge nurse position empty. Staff #6 agreed to work till 11:00PM and then staff #11 would step down into the charge RN position. This would leave no house supervisor until staff #2 could come in at 4:00AM. Staff #6 reported she gave report to staff #11 at 11:00PM.

Staff #12 reported she and staff #13 came on shift at 7:00PM. Staff #12 reported they were not given report and did not know that patient #1 was on a detox program. Staff #12 reported that they were told by staff #3 that they were not to wake the patients at night to assess vital signs. Staff #12 reported staff #3 had told the staff they were not to use flash lights in the room due to it "violated the patients' rights." Staff #12 stated if the MHT's had been given report and was told the patient was on a detox protocol she would have obtained the vital signs every four hours. Staff #12 reported that staff #11 was aware that the patient did not have any vital signs taken and was instructed by staff #11 not to wake the patient. Staff #12 stated it was dark in patient#1's room and the patient was in bed B. The bed was the furthest from the door on the backside wall. Staff #12 stated it was very difficult to tell if she was breathing or not. Staff #12 stated that staff #11 had left the unit unattended several times that evening.

An interview with staff #13 on 2/29/16 reported the MHT's did not get any report on patient's status that shift. Staff #13 stated that he looked in on the male patients and staff #12 checked the female patients. Staff #13 stated that they were instructed not to wake patients by using flash lights or turning on the lights due to violation of their rights. Staff #13 stated he just cracks the door and looks in on them.

Staff #13 reported the morning of 2/25/16, he heard staff #11 screaming for help and asked for somebody to call a code. Staff #13 reported he was instructed to call overhead but didn't know how to work the paging system. Staff #13 stated he used his cell phone to call each unit and report the code. Staff #13 stated staff #10 finally called 911.

An interview with staff #10 (LVN) on 2/29/16 reported that staff #12 and #13 are very good MHT's and were doing their rounds on time. Staff #10 reported that staff #11 was doing all the nursing patient rounds. Staff #10 reported she was busy working on treatment plans that evening. Staff #10 did report staff #11 left the unit for about thirty minutes but she only knew of one time. Staff #10 reported it was ok that the RN left the floor because she was there. Staff #10 reported that the RN's have left the floors before but the Licensed Vocational Nurse (LVN's) were there to supervise. Staff #10 stated that morning she was in the treatment room and heard staff #11 call for help and to call a code. Staff #10 ran down to patient #1's room and found staff #11 performing CPR. Staff #10 reported she told the MHT to go call 911. Staff #10 returned to the patient #1's room and assisted with CPR. Staff #10 stated that was the first time she had used an AED and thought she had felt a pulse in the patient's wrist.


An interview was conducted on 2/29/16 with staff #11. Staff #11 stated she was the charge nurse from 11:00PM until 7:00AM. Staff #11 stated she never talked to the patient. Staff #11 stated she never tried to wake her. Staff #11 stated she was aware that the patient was on a detox protocol but stated, "If our patients are asleep we don't wake them to take vital signs. We just don't do that here." Staff #11 reported the patient was not in her bed at 3:30AM. Staff #11 was unable to say where the patient was. Staff #11 stated, "I assumed she was in the bathroom. When I checked on her at 5:00AM she was ok." Staff #11 reported she went to patient #1's room at 5:50AM and asked her if she was ok. Staff #11 reported she started CPR and Staff #10 brought the crash cart and staff #14 arrived and switched out with me and continued CPR.
Staff #11 reported that staff #2 was there and assisted with CPR. Staff #11 reported that EMS came and put the patient on the stretcher then said they could not take her because she had no vital signs. Staff #11 stated that the patient had a pulse and was breathing just shortly before the code. When staff #11 was questioned on the Asystole reading on the AED and the EMS report that rigor mortis had already set in, staff #11 became defensive and rolled her eyes. Staff #11 stated "I felt a pulse and I don't care what it said."

An interview on 2/29/16 was conducted with staff #8. Staff #8 reported that she was the charge nurse on the 7:00AM-11:00PM shift on 2/24/16. Staff #8 reported that she was walking to the cafeteria with the patients and saw patient #1 staggering up the hallway from the admissions office with a MHT. Staff #8 stated that she told the MHT to go get her a wheelchair so she could take the patient back to the unit. Staff #8 reported the patient was in a sedated state and had a hard time walking. Staff #8 received report on the patient from staff #6. Staff #8 stated she asked staff #6 if she thought the patient needed to go out for medical clearance due to her condition and staff #6 replied, No. The family stated this is her new norm.



These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon observation, record review and interview, the governing body failed to follow their own policy and procedure for Opioid Detoxification. The nursing staff failed to assess and monitor 1 (#1) of 10 (1-10) patients that was admitted for Opioid Detoxification, failed to notify the physician when patient experienced a change in condition, and failed to ensure a Registered Nurse (RN) was available at all times to supervise staff and monitor the needs of the patients. This deficient practice resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.


Refer to Tag A0144, A0395
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observation, record review, and interview, the facility failed to:



A.) follow their own policy and procedure for Opioid Detoxification. The nursing staff failed to assess and monitor 1 (#1) of 10 (1-10) patients that was admitted for Opioid Detoxification, failed to notify the physician when patient experienced a change in condition, and failed to ensure a Registered Nurse (RN) was available at all times to supervise staff and monitor the needs of the patients. This deficient practice resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Refer to Tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon record review and interview, the facility failed to follow their own policy and procedure for Opioid Detoxification. The nursing staff failed to assess and monitor 1 (#1) of 10 (#1-#10) patients that was admitted for Opioid Detoxification, failed to notify the physician when patient experienced a change in condition, and failed to ensure a Registered Nurse (RN) was available at all times to supervise staff and monitor the needs of the patients. This deficient practice resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.

Review of patient #1's chart revealed the patient was admitted voluntarily for Opioid Detox on 2/24/16 at 10:58AM.

The patient was seen by the admissions nurse for a pre-screening assessment on 2/24/16, at 9:17AM. Review of the RN pre-screening assessment revealed patient #1 was a 5'4", 160lb, [AGE] year old white female. Patient #1 was documented as disheveled appearance, slurred speech, intoxicated, anxious, and lethargic. Patient had a history of [DIAGNOSES REDACTED], arthritis and gastric bypass. The vital signs were Temperature 99.1, Pulse 104 (elevated), Blood Pressure 82/64 (low), Oxygen Saturation 97% on room air, pain level 9/10 (1 being no pain and 10 being the worst pain.)

The following medications were documented as patient #1's home medications:

1. Trazadone (is a tetracyclic antidepressant used to treat depression and anxiety disorders) 300mg every evening.

2. Xanax (benzodiazepine for anxiety) 2mg three times a day.

3. Xanax orally disintegrating tablets (ODT) (benzodiazepine for anxiety) 1 mg twice a day as needed.

4. Restoril (benzodiazepines is used to treat insomnia symptoms) 30mg every evening.

5. Flexeril (a muscle relaxant) 10mg twice a day as needed.

6. Torsemide (is a diuretic) 5 mg as needed.

7. Zyprexa (is an antipsychotic medication that affects chemicals in the brain) 25mg daily.

8. Klonopin (benzodiazepines is used to treat seizure disorders or panic disorder) 1mg twice a day.

9. Zubsolv (prescribed for treatment of Opioid Dependence) 8.6/2.1 subling 1 daily.


Review of the RN pre-screening assessment under the "Behavioral Description of the Presenting Problem" stated, "Addicted Xanax-using + 5 yrs. Rx 2mg QID, was on Norco "long time" still using doesn't remember last dose. On Zubsolv for 2 yrs 8.6/2.1 mg subling 1 daily- last today. Increased mdd, crying spells, increased falling, fall asleep at desk, poor sleep at night." The nurse documented in this description the Xanax was prescribed QID (4 x a day) but documented on the medication list that the Xanax was prescribed TID (3 times a day.) Further review of the assessment revealed, "Patient #1's last dose of Xanax was 2/23/16 and used the drug daily."

Review of the RN pre-screening assessment under the "Types of Substance used" revealed the nurse documented, "Patient #1's last dose of Xanax was 2/23/16 and used the drug daily." There was no dosage documented or how often.

Review of the "pre-admission exam & certification" sheet dated 2/24/16, at 10:58AM revealed patient #1 was seen by a physician utilizing telecommunication.

(The facility had a contract with medical doctors (MD) to perform medical evaluations through a tele-monitoring system on patients admitted to the facility. The MD appears on a monitor screen and interviews the patient. The patient can interact back with the physician. The physician relies on the admission nurse for a hands on approach, to observe the patient, take vital signs, inspect the patient's body, and monitor the surroundings as necessary.)

Review of the "pre-admission exam & certification" sheet dated 2/24/16, at 10:58AM, revealed patient #1 was seen by a MD using Telemedicine. The MD documented on 2/24/16, at 10:58AM, "Per MD: 54y/o pt. presents with substance abuse. Using Xanax 4mg daily, last was 2-4 days ago. Zubsolv 8.6/2/1 daily, last was last night. C/o withdrawal SX. Slow response. drowsy." Mental Status Exam section of the doctors exam revealed patient #1 was cooperative, rambling, slow, judgement poor, insight fair, reliability poor, thought psychotic, no suicidal or homicidal ideation.

Review of the admitting physician orders dated 2/24/16 at 10:58AM revealed the following medications were ordered for patient #1:

1. Flexeril 10mg by mouth twice a day as needed for pain.

2. Restoril 30mg by mouth every evening as needed for sleep.

3. Torsemide 5mg by mouth daily as needed for edema.

4. Trazodone 300mg by mouth every evening for sleep.

5. Zyprexa 2.5mg by mouth daily for mood.

6. Zubsolv 8.6/2.1mg was discontinued.


Review of the admitting physician orders for patient #1, dated 2/24/16 at 10:58AM, revealed the following:

1. "Opiate detox protocol"


Review of the policy and procedure "Detoxification from Opiates-General III Nursing Assessment 2.The nurse will contact the psychiatrist to provide a verbal report of the patient's assessment and obtain the Physicians Admission Orders specific to the detoxification as per the patient diagnosis and history."

The initial physician orders were from the telemedicine MD. The MD orders stated to call the "Inpatient psychiatric unit, notifying physician for admission." There was no found documentation that the attending physician was notified.


2. The orders stated, "Labs: CBC with diff/plts, Comprehensive Metabolic Profile, TSH, Liver Panel, UDS, RPR, Lipid Panel, Urine Pregnancy, UA." There was no evidence that any labs were performed.

An interview with staff #3 on 2/29/16, revealed labs are not generally taken upon admission. All labs are collected the following morning. Staff #2 and #3 confirmed patients were treated and administered medications without having initial lab work done to determine any underlying medical issues.


3. Under profile section the physician had marked "no" for pregnancy. Review of the chart revealed there was no documentation of a pregnancy test administered.

Review of the Nursing pre-screening assessment on 2/24/16 at 9:17AM revealed under the "OB-GYN" revealed patient#1 had not had a period in 2 weeks.There was no documentation of a tubal ligation or hysterectomy.


4. Opiate Detox Protocol:

Clonidine 0.1 mg by mouth every 4 hours, hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60.

Dicyclomine 20mg by mouth every 6 hours prn if cramping.

Ibuprofen 600mg by mouth every 6 hours prn if pain or headache.

Methocarbamol 500mg by mouth every 6 hours prn if muscle pain.

Lorazepam 2 mg by mouth every four hours prn agitation. Do not exceed 10mg in 24 hours.


Review of the patient #1's chart revealed the patient's blood pressure was 102/58 at 12:45PM, 105/68 at 4:45PM and 164/77 at 8:45PM. There was no further vital signs documented after 8:45 PM on 2/24/16. There was no documentation that patient #1 received Clonidine or if it was held.


Review of a "PRN Assessment and Narrative" sheet revealed staff #9 administered Tylenol 650mg to patient #1 on 2/24/16 at 5:15PM for a pain scale of 8/10 for lower back pain and was reassessed at 6:15PM "pt asleep." Review of the patient Medication Assessment record (MAR) revealed patient #1 was administered Ibuprofen 600 mg by mouth at 5:15PM not Tylenol. There was no documentation on the MAR that Tylenol was given.


Review of a "PRN Assessment and Narrative" sheet revealed staff #10 administered Trazadone 300mg at 8:30PM due to insomnia and anxiety. Staff #10 documented on 2/24/16 at 9:30PM that patient #1 "was in bed asleep. Respirations even and unlabored. No further complaints of insomnia medication effective." Review of the Mental Health Technicians "q15 minute observation" sheet revealed patient #1 was in the bathroom, not asleep, at 9:30PM.


Review of the MAR revealed on 2/24/16 at 9:00PM patient #1 was administered Ibuprofen 600mg for a second time. The order says every 6 hours as needed. Last dose administered at 5:15PM a difference of 3 hours and 45 minutes. There was no found documentation on why patient #1 was administered the Ibuprofen or if the patient was reassessed.


Review of the MAR revealed on 2/24/16 at 9:00PM patient #1 was administered Methocarbamol 500mg by mouth. There was no found documentation on why patient #1 was administered the medication or the effects of the medication.


5. The physician orders under vital signs stated, "Detox: q4 hours x 24hours then q shift if stable. Notify MD for Systolic blood pressure greater than 160 or less than 90; Diastolic blood pressure greater than 90 or less than 50; Heart rate greater than 12 or less than 60; Temperature greater than 101 or lower than 95.

Review of patient #1 ' s chart revealed an Opioid Detoxification Flowsheet. Patient #1 was assessed and vital signs were taken on 2/24/16 at 12:45PM, 4:45PM and 8:45PM. Review of the flowsheet revealed at 8:45 PM, patient had a blood pressure of 164/77. There was no evidence in the medical record that the attending physician was notified of the elevated blood pressure. There were no further assessments or vital signs found after 8:45PM

Review of patient #1's chart revealed staff #8 (RN) gave report to staff #11(RN) on 2/24/16 at 11:00PM. The following nursing entries were found for patient #1 from 11:00PM -5:50AM on 2/24-2/25/2016:

11:36 PM staff #11 documented, "pt. is in bed sleeping response to noise. Respirations even and unlabored. No acute distress noted at this time. Unable to complete nursing assessment at this time. Will continue to monitor." There was no documentation found explaining why the nurse was unable to assess the patient.

1:30AM staff #11 documented, "Pt. in bed with eyes closed, respirations even and unlabored, breathing normally with rise and fall of chest noted. No acute distress noted. Will continue to monitor."

3:30AM staff #11 documented, "Pt. in bathroom, came back to bed. No acute distress noted. Pt. in bed, breathing normally respirations even and unlabored. No acute distress noted at this time will continue to monitor."

5:00AM staff#11 documented, "Pt. in bed with no distress. Respirations even and unlabored. Rise and fall of Pts. chest noted for normal breathing. Will continue to monitor."

5:50AM staff #11 documented, "Pt. is in bed, this nurse asked Pt. if she would be going to breakfast, no response. Noted pt. is not breathing and unresponsive. Called for help started CPR after placing pt. on the floor. Asked someone to call 911. Compressions given 30 and 2 breaths by mouth. Pt. had a pulse but faint. Compressions continued, gave two breaths, weak pulse, no pulse noted. Continue compressions AED applied on pt. Staff #10 continued CPR. This nurse called the DON on my cell phone, ambu bag being used at this time by staff #14. CPR continued till EMS arrived and took over. Pt. is put on a stretcher. A few minutes later EMS said no vital signs. EMS notified police. Administration notified at 6:14AM, physician notified. Detectives were called by police officers. Information requested by him was provided. Approximately 8:30AM, JP arrived. Family was notified by DON. DON with family at bedside. Body will be released to Lakeside Funeral Home. Belongings released to family per House Supervisor staff #6."


Review of the Cardiopulmonary Resuscitation Flow Sheet revealed the following;

1. CPR was initiated at 5:50AM on 2/25/16.

2. 5:55PM EMS called. There was no found documentation on why it took five minutes to call EMS.

3. The AED (automated external defibrillator) sheets revealed patient #1was in Asystole when the AED was placed on patient#1 at 6:06AM (16 minutes later). There was no documentation found on delay.

(Asystole known as flat line, is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow.)

4. 6:10AM EMS arrived and took over.

5. EMS called the code at 6:14AM.


There was no documented information on what personnel attended the code or what the duties were of that personnel. The signature and discipline on the CPR flow sheet in not legible.


Review of the EMS Report revealed the 911 call was received and dispatched at 5:55AM. The EMS was in route at 5:56AM and at scene at 6:03AM. EMS reached patient #1 at 6:05AM on 2/25/16. EMS documented, "Arrive on scene to find pt. lying in the floor unresponsive with staff doing CPR, Pt has mottled skin (varied patches of color) and cyanosis (blue) around the mouth. Pt has Rigor Mortis in the hands and in the jaw. CPR efforts are withheld at this point." (Rigor mortis is one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Rigor mortis occurs three to four hours after death.)

Review of the incident report revealed the date of the incident was 2/25/16 at 5:50AM on unit 4 room 409B. Patient #1 was involved and staff #11. The incident checked was "medical problem/911." Review of the second page of the incident report has "incident report" marked through with a pen and written in was "employee statement." A written statement was made with no signature of person making the statement. The "actions taken" section was left blank. The signature line for "report completed by" and time was left blank. The employee written statement revealed the patient went to the cafeteria to eat at 4:15pm and returned to the unit at 6:30PM. "I announced about going to A.A. and she replied yes she wanted to attend then I got her q 15 min observation sheet and went back down the hallway to ask other patients and she stopped me in the dayroom and asked what it was I said. I told her and she said she thought I asked if she wanted an egg. I replied no mam and then she wanted me to take her back to her room and then that's when med nurse took her to her room and after then that's when I took the other patients to A.A."

Review of the MHT Q15 minute observation sheets revealed Patient #1 was documented attending an A.A. meeting from 6:45PM until 7:45PM. There was no clear documentation on where patient #1 was during this time frame.

An interview was conducted with staff #3 (Risk Manager) on 2/29/16. Staff #3 reported she arrived at the facility after the code on 2/25/16. Staff #3 reported that review of the chart revealed Staff #11 had not written her nurses notes for Pt. #1 for the shift. Staff #3 stated Staff #11 wrote the shift notes after the incident.

An interview was conducted with staff #6 and staff #12 on 2/29/16. Staff #6 reported that staff #11 was assigned as the house supervisor on the night shift of 2/24-2/25/2016. The charge nurse called in and left the RN charge nurse position empty. Staff #6 agreed to work till 11:00PM and then staff #11 would step down into the charge RN position. This would leave no house supervisor until staff #2 could come in at 4:00AM. Staff #6 reported she gave report to staff #11 at 11:00PM.

Staff #12 reported she and staff #13 came on shift at 7:00PM. Staff #12 reported they were not given report and did not know that patient #1 was on a detox program. Staff #12 reported that they were told by staff #3 that they were not to wake the patients at night to assess vital signs. Staff #12 reported staff #3 had told the staff they were not to use flash lights in the room due to it "violated the patients' rights." Staff #12 stated if the MHT's had been given report and was told the patient was on a detox protocol she would have obtained the vital signs every four hours. Staff #12 reported that staff #11 was aware that the patient did not have any vital signs taken and was instructed by staff #11 not to wake the patient. Staff #12 stated it was dark in patient#1's room and the patient was in bed B. The bed was the furthest from the door on the backside wall. Staff #12 stated it was very difficult to tell if she was breathing or not. Staff #12 stated that staff #11 had left the unit unattended several times that evening.

An interview with staff #13 on 2/29/16 reported the MHT's did not get any report on patient's status that shift. Staff #13 stated that he looked in on the male patients and staff #12 checked the female patients. Staff #13 stated that they were instructed not to wake patients by using flash lights or turning on the lights due to violation of their rights. Staff #13 stated he just cracks the door and looks in on them.

Staff #13 reported the morning of 2/25/16, he heard staff #11 screaming for help and asked for somebody to call a code. Staff #13 reported he was instructed to call overhead but didn't know how to work the paging system. Staff #13 stated he used his cell phone to call each unit and report the code. Staff #13 stated staff #10 finally called 911.

An interview with staff #10 (LVN) on 2/29/16 reported that staff #12 and #13 are very good MHT's and were doing their rounds on time. Staff #10 reported that staff #11 was doing all the nursing patient rounds. Staff #10 reported she was busy working on treatment plans that evening. Staff #10 did report staff #11 left the unit for about thirty minutes but she only knew of one time. Staff #10 reported it was ok that the RN left the floor because she was there. Staff #10 reported that the RN's have left the floors before but the Licensed Vocational Nurse (LVN's) were there to supervise. Staff #10 stated that morning she was in the treatment room and heard staff #11 call for help and to call a code. Staff #10 ran down to patient #1's room and found staff #11 performing CPR. Staff #10 reported she told the MHT to go call 911. Staff #10 returned to the patient #1's room and assisted with CPR. Staff #10 stated that was the first time she had used an AED and thought she had felt a pulse in the patient's wrist.


An interview was conducted on 2/29/16 with staff #11. Staff #11 stated she was the charge nurse from 11:00PM until 7:00AM. Staff #11 stated she never talked to the patient. Staff #11 stated she never tried to wake her. Staff #11 stated she was aware that the patient was on a detox protocol but stated, "If our patients are asleep we don't wake them to take vital signs. We just don't do that here." Staff #11 reported the patient was not in her bed at 3:30AM. Staff #11 was unable to say where the patient was. Staff #11 stated, "I assumed she was in the bathroom. When I checked on her at 5:00AM she was ok." Staff #11 reported she went to patient #1's room at 5:50AM and asked her if she was ok. Staff #11 reported she started CPR and Staff #10 brought the crash cart and staff #14 arrived and switched out with me and continued CPR.

Staff #11 reported that staff #2 was there and assisted with CPR. Staff #11 reported that EMS came and put the patient on the stretcher then said they could not take her because she had no vital signs. Staff #11 stated that the patient had a pulse and was breathing just shortly before the code. When staff #11 was questioned on the Asystole reading on the AED and the EMS report that rigor mortis had already set in, staff #11 became defensive and rolled her eyes. Staff #11 stated "I felt a pulse and I don't care what it said."

An interview on 2/29/16 was conducted with staff #8. Staff #8 reported that she was the charge nurse on the 7:00AM-11:00PM shift on 2/24/16. Staff #8 reported that she was walking to the cafeteria with the patients and saw patient #1 staggering up the hallway from the admissions office with a MHT. Staff #8 stated that she told the MHT to go get her a wheelchair so she could take the patient back to the unit. Staff #8 reported the patient was in a sedated state and had a hard time walking. Staff #8 received report on the patient from staff #6. Staff #8 stated she asked staff #6 if she thought the patient needed to go out for medical clearance due to her condition and staff #6 replied, No. The family stated this is her new norm.



These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.