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MILWAUKEE COUNTY BEHAVIORAL HEALTH DIVISION 9455 W WATERTOWN PLANK RD MILWAUKEE, WI 53226 Oct. 12, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
Based on staff interview and record review, it was determined the facility failed to ensure that one of one patient received proper assessments, evaluation and appropriate interventions after the patient (Pt #1) was found lying face down on the floor and reported being unable to move lower extremities. The lack of monitoring and assessing and providing appropriate interventions led to the death of 1 of 1 patient (Pt. #1). These failures had the potential to affect any patient experiencing a medical emergency.

Findings include:

Review of Pt. #1's medical record for the time period of 10/3/2012 through 10/6/2012 , indicates the facility had knowledge of Pt #1 being unable to move lower extremities status post unwitnessed fall. As a result of the facility's lack of monitoring, assessments, interventions, and evaluations, actual harm did occur resulting in the death of Pt #1. This situation led to an immediate jeopardy at tag 0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the facility failed to ensure that one of one patient received proper assessments, evaluation and appropriate interventions after the patient was found lying face down on the floor and the patient reported being unable to move lower extremities. The lack of monitoring, assessing, evaluation and providing appropriate intervention, led to the death of 1 of 1 patient, Pt. #1. These failures had the potential to affect any patient experiencing a medical emergency.

Findings include:

Review of Pt #1's MR beginning on 10/11/2012 at 8:50 AM reveals on 10/3/12 at 8:14 AM [AGE] year old Pt #1 was transferred from home to the PCS (Psychiatric Crisis Service) unit via Milwaukee Police Officers, in response to behavior consisting of standing outside house in sleepwear with no shoes, looking confused, drooling, unresponsive, and crawling down the stairs on hands and knees making no sense. MR also reports Pt #1 fasting for four days, refusing food and water, becoming irate, combative, and refusing to cooperate with Milwaukee Police. Chief complaint in patient ' s words is documented as follows, "I don't know why I'm here, I was on the floor sleeping not crawling, there's nothing wrong with me, I remember everything, I was not out of control."

Review of Pt #1's Medical Screening Exam conducted by MD W on 10/3/12 at 9:07 AM documents Pt #1 as "Health looking", "no sign of trauma", "no objective signs of intense pain" , "no sign of severe head trauma" , "no new onset of sensorimotor deficits (sensory and motor activity)" . Per MD W's note on 10/3/12 at 10:00 AM, "(Pt #1) refuses transfer to a medical acute care hospital for medical clearance and given patient presentation as healthy, not delirious, seems well nourished, will defer transfer to ER as patient seems likely to erupt or elope ... "

Review of Pt #1's Abnormal Involuntary Movement Scale (AIMS) conducted by MD W on 10/3/12 at 10:55 AM documents Pt #1 as having normal movements of upper and lower extremities.

Review of Pt #1's Physician Diet Orders dated 10/3/12 at 10:55 AM reveal orders for a regular diet and regular texture.

Per review of "Nursing Assessment of Mental Status on Admission to Unit" documented on 10/3/12 at 2:45 PM by RN F, reveals initial interview with Pt #1 on arrival to inpatient unit 43 D. Per interview with RN F on 10/11/12 at 11:25 AM, RN F stated Pt #1 came up to the unit ambulatory with no complaints of pain, Pt #1 met with RN F and Psychologist M in office. Per RN F Pt #1 was anxious and restless and was noted to have been walking back and forth in front of nursing station prior to entering office. Per RN F Pt #1 answered questions appropriately, denied all allegations of reasons for admission and stated (Pt #1) wanted to leave. Per RN F work shift was ending so full physical assessment was not completed by RN F, initial information was passed on to RN E on 2nd shift.

Per interview with CNA U on 10/12/12 beginning at 2:15 PM, on 10/3/12 after arriving on the unit, Pt #1 was seen pacing the nurse ' s station and walking around exploring the unit. Per CNA U, at approximately 5:30 PM CNA performed 15 minute check and could not find Pt #1. CNA U then heard someone calling out for help and realized the sound was coming from Pt #1's room. CNA U then attempted to open Pt #1's door and noticed a folder in the door jam inhibiting CNA from opening door. CNA U then flagged down RN E (Pt #1's nurse), and RN E pushed the door open. Per CNA U witnessed Pt #1 on the floor, face down, near the window; Pt #1 stated, "I fell , I'm paralyzed." Per CNA U, did not witness Pt #1 move legs after finding Pt #1 on the floor.

Per incident report documented by RN E dated 10/3/12 at 5:40 PM. The incident report states, "(Pt #1) found down in room saying he could not move, (Pt #1) had recently been ambulating and was checking doors, Pt said he fell -no evidence of any kind of injury. Pt just said I can't move my legs and asked to be sent out to a specialty hospital to get checked out."

Per review of RN E's progress note documented on 10/3/12 at 6:30 PM, RN E documented, "Pt did not have any apparent physical trauma ...AR (Administrative Resource) and Physician on duty (POD) notified, POD up to unit to assess Pt's physical status ...Pt continues to state he needs to go to a specialty hospital because he is paralyzed ...attempted to get patient up into bed but could not because of (pt #1's) weight. Mattress placed on floor and pt was rolled onto the mattress."

Per review of RN E's Admission Physical Assessment documented on 10/3/12 at 7:30 PM, "Weakness, c/o Paralysis" is documented. The check boxes for "Stiffness/soreness", "Limited ROM (range of motion), " Hx (history) of falls" , "Gait" are all blank. Referral for Falls Assessment is checked "no" . "Other findings " under Neurological assessment states, "states he can't move his legs." Cardiovascular assessment is blank for "peripheral circulation findings" .

Per review of Pt #1's MR, there is no evidence of initiation of a individual care plan related to safety and fall prevention, mobility, or skin integrity related to Pt #1's current physical presentation and recent history of an unwitnessed fall. No evidence of increased monitoring of neurological status and loss of function of lower extremities post unwitnessed fall. No evidence of a falls risk assessment completed for Pt #1. No evidence of post-fall huddle completed including the interdisciplinary team per Fall Prevention: Identification and Management of Individuals at Risk Policy and Procedure, last revised 5/2010. No evidence of a referral to PT/OT for evaluation post fall. Per interview on 10/12/12 beginning at 4:25 PM with OT V, a referral should be initiated post fall and then OT would have 24 hours to evaluate patient.

Per interview on 10/11/12 at 4:20 PM with RN E, when asked by surveyor if any increased monitoring, assessment, or interventions were done of Pt #1's neurological status and physical change of condition post unwitnessed fall, RN E responded, "I looked in on (Pt #1) every 30 minutes." When asked if RN E did a physical assessment of Pt #1 post fall during shift and RN E responded, "no." Per RN E, "checks are not done as often on unwitnessed falls without injury." RN E stated, "It's subjective." Per RN E, Pt #1 was not moving legs during initial assessment post fall. Per RN E, lifted up Pt #1's leg and released it to see if Pt #1 would stop leg from hitting the floor, Pt #1's leg hit the floor and pt #1 responded by saying, "ouch."

Per review of Psychiatrist G progress notes documented on 10/3/12 at 6:25 PM, Pt #1 seen at the request of nursing staff. Psychiatrist G documented, "Pt found by writer in room, Pt states he can't move, needs to go to hospital ...Pt states he hit his head, but when asked where he won't respond ...no trauma noted to head ...Pt reports pain... (Pt #1) is noted to intermittently move left foot ...(Pt #1) refused to discuss reason for admission, repeats he wants to go to hospital." Psychiatrist G also documented, "Given Pt's history of similar bx (behavior) at home per ED, unwillingness to provide any report, self-concealment at time of alleged fall, it is highly unlikely he had a traumatic fall or injury ...no signs of trauma on brief exam ...medicine team to f/u (follow up) tomorrow."

Per interview on 10/11/2012 beginning at 1:05 PM Psychiatrist G stated G is a 3rd year Psychiatry resident. Psychiatrist G stated G was the POD on 10/3/12 and was called by staff to assess Pt #1 post unwitnessed fall. Psychiatrist G stated G was told by RN that Pt #1 had been up walking around unit checking doors prior to unwitnessed fall. Per Psychiatrist G, entered room and observed Pt #1 lying on floor, Pt #1 was not moving lower extremities. Per Psychiatrist G observed head for trauma, moved Pt #1's legs and Pt #1 reported pain with movement, left foot would move a little bit during exam; no other assessments done except moving around head and legs and checked pupils. Psychiatrist G determined it was not necessary to send pt #1 out to ER to get medical clearance due to history at home of lying on the floor. Psychiatrist G stated "seemed to be the same behavior exhibited at home." Per Psychiatrist G, in a situation of an unwitnessed fall, only would have ordered additional monitoring if assessment showed acute neurological changes. When asked by surveyor if it is possible for neurological symptoms to manifest over time and Psychiatrist G responded, "Yes" .

Review of Pt. #1's MR show Nursing Assessments and RN progress notes from 10/3/12 to 10/6/12 and reveals the following documentation of Pt #1's mobility:

10/3/12:
7:30 PM-"Weakness, Pt complaining of paralysis" (RN E)
8:00 PM-"Continued to state he was paralyzed and needed to go to a specialty hospital"
(RN E)
10/4/12:
6:00 am- "Still lying on his mattress" (RN BB)
10:15 am-"Claims to be paralyzed" (RN X)
2:00 PM-"Pt was still refusing to get off mattress on floor" "claims he was paralyzed" (RN X)
9:50 PM- "Client up in geriatric chair most of shift, refused to ambulate, stand or move
lower extremities" (RN Y)
10:00 PM- "diminished muscle strength, requested crutches" "wearing depends"
"Clients depends saturated" (RN Y)

10/5/12:
8:30 am-"Pt continues to be unable to sit or stand wants geriatric chair".(RN Z)
10:15am-"Continues to lie on floor mattress" "refusing to get up states is paralyzed
from waist down" (RN Z)

2:00 pm- "Per Pt paralyzed" "unsteady gait, difficulty walking, active fall risk"
"Incontinent" (RN Z)
4:00 pm- "Patient claimed he is paralyzed down the waist, cannot walk" (RN AA)
9:00 pm- "Patient is not cooperative and will not use his BLE or BUE "
"Unable to hold food or glass in his hands " (RN AA)
10:30 pm- "Immobility" "refuses to move" "Incontinent" "wears diapers due to pt claiming he
is paralyzed" (RN AA)
10/6/12:
6:00 am- "Said he needed help because he cannot get up and he needs water"
"encouraged patient to get up" (RN F)
7:45 am- "up in geriatric chair" "medication crushed in pudding "
9:20 am-Code 4 called, pt unresponsive (RN Y)

The above nursing assessments are derived from approximately 7 different Registered Nurses. MR for Pt #1 shows no proper assessments, or interventions, or evaluation of Pt #1's complaints of lower extremity paralysis post unwitnessed fall.

Per interviews on 10/11/12 and 10/12/12, 9 staff members who cared for Pt #1 on 10/4/12, 10/5/12, and 10/6/12 denied ever having knowledge of Pt #1 having an unwitnessed fall on 10/3/12: RN F, OT J, RN K, Psychiatrist L, Psychologist M, NP O, MD F, CNA P, RN Q.

On 10/15/12 Department of Health Services staff requested the Medical Examiner's report on Pt #1's cause of death and was denied access due to the report being under "non-disclosure" by the Sheriff's Department. Per Milwaukee County Sheriff news interview, Pt #1 died of a fractured neck leading to a blood clot traveling to pt #1's legs and then into lungs.