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.

Based on observation, interview, and record review, the facility failed to evaluate the care of the Patient 1 in accordance to the hospital policy when:

1a. There was no documentation of monitoring or observation rounds from 5 PM to 11:45 PM (seven hours) on 6/3/18.
1b. Patient status, activity, and assessment of environment was not indicated at the monitoring or observation rounds.
1c. Engagement Rounds was done by Patient Care Assistant (PCA) or Medical Evaluation Assistant (MEA) instead of licensed nursing staff as indicated in the policy.

2. The emergent medication given on admission (6/3/18 at 12:30 PM) was not evaluated for effectiveness.

Failure to monitor patient condition could potentially hinder prompt detection of adverse event.


Review of the Event Summary from the facility indicated, Patient 1 was brought to the Psychiatric Emergency Services (PES) on 6/3/18 by the Police Dept. who placed the patient on 5150 hold (danger to self/others). Patient 1 had a history of schizophrenia ( Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn and may have difficulty expressing normal emotions in social situations.) and poly-substance abuse. She was triaged, assessed by nursing, and evaluated by the medical provider. At approximately 6 AM, in preparation for a planned am discharge, the patient was approached by staff who found her pulseless and apneic. CPR (cardio-pulmonary resuscitation) was initiated. Code Blue was activated. (Medical Definition of Code blue. Code blue: An emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers [sometimes called a 'code team'] to rush to the specific location and begin immediate resuscitative interventions)

Patient 1 was pronounced dead at 6:20 AM.

Review of the Coroner's Report dated 6/5/18 showed the cause of death was pulmonary thromboembolism ( An obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation.) due to lower extremity deep vein thrombosis.

According to, retrieved on 6/19/18, "5150 refers to the California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness."

1a.b. Review of "Psychiatric Emergency Services (PES) Management Rounds" documentation, indicated a 15 minutes interval monitoring boxes. The PES Management Rounds monitoring for Patient 1, dated 6/3/18 was started at 12:30 PM, indicated a "T" which means "Triage", and an "H" which means "Hall" from 12:45 PM up to 4:45 PM. The monitoring boxes from 5 PM up to 11:45 PM was blank (no entry).

During an interview on 6/11/18, at 7:15 AM, Licensed Vocational Nurse (LVN) 1 stated that she worked night shift on 6/3/18 (11 PM to 7 AM). According to LVN 1, Patient 1 was in the hallway near the restroom and she was not aware if the patient got up during her shift.
LVN 1 confirmed that she did the management rounds on 6/4/18, from 12 AM up to 6 AM. She explained that during her rounds she checked and document the location of the patient.

During an interview on 6/11/18, at 7:15 AM, Registered Nurse (RN) 1 stated, he was the night shift charge nurse on 6/3/18 (7 PM to 7 AM). RN 1 stated, he received the report from outgoing nurse that Patient 1 had been sleeping all day. RN 1 also stated, "Generally I walked around the unit. I was given a map where everybody was situated."

During an interview, on 6/7/18, at 1:58 PM, the Nursing Director (ND) explained that the PES staff were using two monitoring records, the Management Rounds which is done by Licensed staff and the Hallway Rounds, which served as "engagement" rounds done by either PCA or MEA. The ND stated, "The Management Rounds documentation indicated, "...the location not an activity of the patient. It is not clarified (referring to the status of the patient)." The ND also acknowledged that there was no monitoring entry for Management Rounds between 5 PM to 11:45 PM, and for Hallway Rounds between 12 NN up to 5 PM.

Review of the facility policy titled, "Patient Observation Rounds Policy" dated June 2016, indicated, "...Every patient admitted to Acute and Emergency Psychiatry will be observed and monitored at a minimum of every 30 minutes by a licensed nursing staff member. Patient on unit 7L and PES will be monitored by a licensed nursing staff member every 15 minutes. The environment of care will be monitored for safety and security with each set of rounds...Procedure A. Patient observation rounds include: 1. Direct observation of the patient and what they are doing. 2. The location of the patient. 3. The status of the patient. 4. Providing emergent intervention as indicated by the situation. 5. Communication with the charge nurse or assigned nurse if a patient requires a nonemergent intervention. 6. Testing the security locked areas. 7. Assessment of environment (patient room and public areas) for patient safety risks..."

1c. Review of "PES Hallway Rounds" documentation, indicated an hourly interval monitoring boxes. The Hallway Rounds monitoring for Patient 1, dated 6/3/18 was started at 6 PM up to 6 AM the following day (6/4/18). There was an "S" from 7 PM (6/3/18) up to 6 AM (6/4/18) which means "Sleeping" and an "NM" at 2 AM (6/4/18) which means "Needs Met." The monitoring boxes from 12 NN to 5 PM was blank (no entry). There was no signature or initial of the staff who completed the monitoring documentation.

During an observation, on 6/8/18, at 10:59 AM, PCA 1 was sitting in the hallway. During concurrent interview, PCA stated, she was assigned to do the Hallway monitoring. PCA 1 also stated that she's doing her documentation at monitoring book.

During an interview, on 6/12/18, at 7:24 AM, the Medical Evaluation Assistant (MEA) 1 stated, on 6/3/18, night shift (11 PM to 7 AM) and was assigned to do the hallway monitoring. The MEA 1 added, she did the visual observation of Patient 1 and completed the hourly documentation at PES Hallway Rounds record. She explained that for Patient 1, she documented "S" (sleeping), from 12 MN to 6 AM and NM (need met) at 2 AM.

Review of the facility policy titled, "Patient Engagement Rounds" dated, June 2016, indicated, "...Procedure for performing engagement rounds: 1. Assignment of engagement rounds to licensed nursing staff will be done outside of the routine Patient Safety/Observation rounds. Engagement rounds are in addition to Patient Safety/Observation rounds. 2. Assigned licensed nursing staff will perform engagement rounds at the top of the even hour, between 8 AM and 10 PM... 5. Assess for any significant change in appearance or behavior. 6. Report any pertinent clinical findings/findings of concern to patient's MD (doctor) and charge nurse..."

2. Review of Patient 1's "One-Time Medications" record, dated 6/3/18, indicated, Ativan (anti-anxiety) 2 mg (milligram), Benadryl (antihistamine) 50 mg, and Risperdal (antipsychotic) 2 mg was given to Patient 1 at 12:30 PM. There was no reassessment of the result and patient response to the medication.

Review of the facility policy titled, "Administration Of Medications", dated 10/17, indicated, "...M. Documentation...2. For PRN (as situation demand)/ One Time medications, documents the reason for and response on the appropriate medication administration record..."
Based on interview and record review the facility failed to provide emergency services in accordance with acceptable standards of practice when there was no oxygen tank available in the Psychiatric Emergency Service (PES) crash cart during the code blue incident on 6/4/18.

The deficient practice may have caused delay in provision of needed intervention and likely to adversely affect patient outcome.


Review of Patient 1's "Code Blue Note" dated 6/4/18, indicated, "...Indication(s) for Code Blue Activation: Hypoxia (deprivation of oxygen)...Code Blue Outcome...Efforts terminated due to lack of sustained return of circulation..."

Review of "Respiratory Care Services Respiratory Care Therapy Record" dated 6/4/18 at 6:55 AM, indicated, "Call to PES for code blue...started with ambu bag FiO2, 21. Unable to obtain O2 (oxygen) tank from crash cart..."

According to, FiO2 is the fractional concentration of inspired oxygen. The typical concentration of room air is 21%.

During an interview, on 6/11/18, at 7:56 AM, Registered Nurse (RN) 1 acknowledged that there was no oxygen tank at the crash cart during the code blue on 6/4/18. RN 1 also stated that he did not check the crash cart before the start of his shift.

Review of the facility policy titled, "Crash Cart Checks and Replacement", dated 3/17, indicated, "...Statement of Policy 1. The Registered Nurse or Licensed Personnel as designated by the unit/department is responsible for checking the unit/department crash cart to ensure...that emergency equipment is available and in usable condition...4. One standardized crash cart checklist form is furnished on each cart and will be used for both adult and pediatric crash carts (See Appendix B: Crash Cart Checklist)..."

Review of "Appendix B...Crash Cart Checklist", dated 10/2017, indicated, "...Oxygen tank is present (and) full..."