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CHIPPEWA COUNTY WAR MEMORIAL HOSPITAL 500 OSBORN BLVD SAULT SAINTE MARIE, MI 49783 Jan. 29, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon document review, interview and policy review the facility failed to ensure care in a safe setting for one of twelve patients (pt.#3) resulting in the death of a patient. Findings include:

1. The facility failed to provide care in a safe setting to 1 of 12 patients (pt.#3) resulting in the death of a patient. See tag A-0144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, interview, and policy review the facility failed to provide care in a safe setting for one of twelve patients (#3) resulting in the death of a patient. Findings include:

On 01/28/2019 at approximately 1030 review of facility incident reports revealed on 01/24/2019 at 0006 patient #4 was found standing over patient #3. Patient #3 was unresponsive and later pronounced dead. Patient #4 was transferred to the custody of the local police department.

On 01/28/2019 at review of patient #4's medical record revealed:

Patient #4: a [AGE]-year-old 6'4'' 293-pound male patient was admitted at 0316 on 01/18/2019 to room 108 bed A. Diagnosis: schizophrenia, paranoid subtype, schizoaffective disorder, paranoid delusions. Medical History: Hypertension, arthritis, back pain and obesity. Substance Abuse History: Cigarettes, Marijuana, and alcohol.
Internal Medicine history and physical (H&P) by Nurse Practitioner stated, "Patient has also expressed having homicidal thoughts towards anyone, will let you know if I have a plan."
On 01/18/2019 at 0606 staff R (RN) documentation stated, "Patient found on the floor with the mattress over the top of him.' The patient stated, "Hearing gunshots and thought someone was firing at him."Admission orders included 1:1 supervision that was removed at midnight.

The psychiatric evaluation was completed on 01/19/2019 by Staff J Medical Director. When the patient was asked about homicidal ideations the patient stated "Yes, but I am not going to give you names. You don't need to know more about this" he also stated, "Despite these people looking like they are casual, they want to disguise themselves and I will defend myself and kill them." He would only agree to take medications to help him sleep.

On 01/19/2019 at 1258 patient #4 was seen by Staff O Psychologist. The patient stated "prepared to hurt others to protect myself and others. I'm not a homicidal man. I'm not a killer." Staff O documentation reported symptoms: anxiety, depression, mood swings, paranoia, homicidal ideation, abnormal sleep pattern.
On 01/19/2019 at 2357 Staff R (RN) documented when nurse entered room and called patient #4's name "he jumped up and postures himself as if he was going to attack" he stated, "I am sorry I felt a presence in the room before you entered."

On 01/20/2019 at 1237 patient #4 was seen by Staff O Psychologist. The patient was documented as stating " ...would hurt somebody as a second strike, in self-defense. I'm not a homicidal killer." Staff O documented reported Symptoms: anxiety, difficulty concentrating, confusion, irritability, paranoia, homicidal ideation.
On 01/20/2019 at 2000 nursing assessment states "patient is fearful, anxious, believes others are watching him, suspicious of staff."
On 01/20/2019 at 1439 Patient #4 moved from room 108 bed A to room 102 bed A (59 hours after admission, and 30 hours after documentation of making Homicidal ideation statements.)

On 01/21/2019 at 1624 Staff R Registered Nurse (RN) nurse documentation states "Patient (#4) through out the day has expressed to another staff member to stay away from him and to not enter his room, she explained that she was caring for his roommate, regardless he still asked her to stay out of his room." The patient reported feeling "fearful, scared, afraid and nervous."

Patient #4 did not sleep all night the night of 1/21-1/22 documentation states "total sleep 30 minutes, patient was up all night, too paranoid to fall asleep." Every 15 minute safety checks documented patients location and activity- only 30 minutes observed in bed with eyes closed.

On 01/22/2019 at 1347 patient #4s documentation staff P (RN) stated "denied suicide or Homicide ideations. Patient reported hearing voices ...he stated he does not take direction from them ...spirit passed through him ...and patient not open to reorientation ..."
On 01/23/2019 at 1212 patient #4 was seen by Physician Assistant Staff T. Patient reported "occasional intermittent auditory hallucinations ..." Documentation states "Patient remains paranoid ...he is not sleeping ...discussed with (Staff J) to add mood stabilizer ..."

Staff D (RN) documented the following:
On 01/23/2019 at 2150 Yelling heard from patients' room, patient #4 sitting up on side of bed, reported having nightmare but would not give details ...given sleep aide."
On 01/23/2019 at 2206 patient #4's mattress found removed from bed, patient #4 on floor beneath mattress ...assisted back to bed.
On 01/23/2019 at 2250 Patient #4 to nursing station with c/o chest pain ...assessed ... Mylanta ...after 10 minutes falling asleep in chair, returned to room stated to staff "you don't need to follow me, leave me alone" and closed the door.
At next 15-minute check 2345 patient #4 resting quietly in bed with eyes closed.

*No other documentation was found of interventions related to the increased behaviors during the evening of 01/23/2019.

At 0006 on 01/24/2019 Staff R (RN) documented: Patient #4 was found on right side of roommate's bed in squatting position. RN further entered room because roommate's walker was present, but roommate was not visible. Patient appeared frightened by RN coming closer to further assess the situation as the only light in the room was a small night light. RN noted this patient was squatting on top of roommate (patient #3) with his hand on roommate's head and roommate appeared folded in half. Patient #4 started to come toward RN quickly with his hand up and one to his mouth stating Shhh!!Shhh!!RN ran out of room and called for help

On 01/24/2019 at 03:59 discharged into police custody.

Care Plan/Plan of care;
Suicide/Homicide, safety, Level of consciousness, Presentation, mood, affect, behavior, Hallucinations, delusions, thoughts, sleep, speech, anxiety, program participation, appearance, pain, risk. These are documented every 12 hours as assessed by RN.

On 01/29/2019 at 0900 Staff J Medical Director of the Behavior Health Center was interviewed. Staff J- explained: Patients who verbalize homicidal ideations are placed in a room without a roommate for the first 72 hours after admission, while beginning medications and therapy. Once the medications have had time to begin working and the paranoia decreases, we re-evaluate in the morning safety huddle, if everyone agrees, the patient can be moved into a semi-private room with a roommate. A physician's order is not needed to move the patient into a semi-private room. Staff J stated, "there is no policy outlining this practice." Staff J further stated "I assessed patient #4 on 1/23/2019, he responded to the homicidal ideation questions, I would only defend myself as a second strike."
Staff J went on to explain "I never felt threatened by patient #4, he appeared rational. Patient #4 participated in group and even sang karaoke Wednesday evening (1/23) with the other patients." Staff J stated, "Patient #4 was observed being friendly to and taking care of patient #3."

On 1/29/2019 at approximately 1000 Staff D-RN worked the afternoon shift on 1/23/2019 was interviewed.
Staff D was asked about the room assignment process considering Homicidal/Suicidal patients and safety, she explained for the first 72 hours approximately, patients are kept in a room by themselves, suicidal patients have a 1:1 sitter for safety,15-minute safety rounds are conducted, patient's mood/state of being is assessed if awake. Any out of the normal response is reported to the RN that is assigned to that patient and medications can be given.
Staff D was asked how do you decide that a patient is safe to move in to a semi private room with a roommate. Staff D stated "The day shift staff discusses patient progress in the morning safety huddle, that discussion is not documented anywhere, and we do not get a physician order to discontinue a No Roommate Order."
Staff D continued to explain, as soon as a patient stabilizes with medications and therapy, we try to pair patients up, it can be very beneficial, the support improves the effect of therapy. Staff D stated, "Patient #3 and #4 appeared to be getting along well, patient #4 had a caring attitude towards patient #3, he would help him with things like opening doors and pulling out chairs on the unit."

On 1/29/2019 at approximately 1100 Staff R-RN who came in to work at 2330 on 1/23/2019 was interviewed. Staff R was asked about the room assignment process considering Homicidal/Suicidal patients and safety, she explained for the first 72 hours approximately patients are kept them in a room by themselves, suicidal patients have a 1:1 sitter for safety, 15-minute safety rounds are conducted. She stated patients are asked how they feel and usually are pretty honest about what they are feeling. Any out of the normal response including pain, anxiety, suicidal/homicidal statements are reported to the RN assigned to that patient and medications can be given. The day shift holds a safety huddle every morning, that discussion is not documented. Staff R was asked how the afternoon and midnight shifts could have input into the discussion, Staff R stated, "We give report to the day shift and they can discuss concerns we have." Staff R continued, "We do not get a physician order to discontinue a No Roommate Order. As soon as a patient stabilizes with medications and therapy, the staff all agree, we try to match patients up."

On 1/29/2019 at approximately 1330 Staff P- RN who worked day shift on 1/23/2019 was interviewed regarding patient #4. Staff P reported that on 1/23 she was assigned patient #4. She reported that on that day patient #4 was not homicidal, or suicidal, he was not irritable, he took his medications, he got along with the other patients on the unit and had no problems. Staff P was asked about the room assignment process considering Homicidal/Suicidal patients and safety, she explained that for the first 3 days approximately patients are kept them in a room by themselves, suicidal patients have a 1:1 sitter for safety, staff make every 15-minute safety rounds. If patients are awake, "we ask them how they are feeling? Any response that can be treated, I can look up additional medications that are ordered and give the patient what they need. If I need to, I can call the physician for orders. If a patient really becomes agitated, we can use restraints, but we try to deescalate before that happens." Staff P was asked about the safety huddle, she stated "all patient progress is discussed, that discussion is not documented anywhere, and we have not been required to get a physician order to discontinue a No Roommate Order we just erase it from the white board and move the patient."
Staff P stated, "Patient #3 and #4 really seemed to get along well. I did not hear negative comments from either patient."

On 1/29/19 at approximately 1500 Staff O Psychologist was interviewed regarding patient #4. Staff O reported that he had seen him for evaluation a total of 3 times. He stated "He was ill, delusional but not homicidal. He always responded that he would defend himself if needed."

On 1/29/2019 at 1300 the policy titled "Hourly Rounding on Inpatients" dated revised 6/19/2018 was reviewed. On page one of one under #1 it states "Hourly rounding will be managed by the care team."
On 1/29/2019 at 1300 the policy titled "Routine Observations Rounds (Fifteen Minute Checks)" dated revised 3/29/2018 was reviewed. On Page one of two under Purpose it states "To maintain a safe environment and ensure the safety and the whereabouts of patients on a routine basis."

On 1/29/2019 at 1400 the policy titled "Admission Orders" dated revised 07/10/2018 was reviewed. On page one of two it states "To ensure that when a patient is admitted to the Behavioral Health Center, the physicians orders will be complete and inclusive of any psychiatric or medical co-morbidities. Continuing treatment orders will reflect active treatment elements throughout the hospitalization period...#4. Precaution levels (e.g. suicide, assaultive...) #5. Frequency of patient observation (e.g. 15 minute checks, line of sight, ect.)..."