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Based on facility document, and staff interview, the registered nurse failed to supervise and evaluate the nursing care for an involuntary patient (ID#A) when he was in distress as reported by the Licensed Vocational Nurse (ID#14), and ultimately died.

Findings Include:

Facility policy "Medical Risk Acute Change of Condition" that was last reviewed on 12/14/20 stated "to ensure staff is trained to recognize warning signs of clinical deterioration in a patient's medical condition and know what action is to be taken.

Record review the incident report revealed the licensed vocational nurse (LVN) (ID #14), and mental health technician (ID#13) notified the registered nurse (RN) (ID#15) of the change in condition at 4:30 p.m. The RN did not go into the patient's (ID#A) room until 5:52 when the code began.

Interview with staff (ID #12) who stated, "we did a root cause analysis, and as a result we no longer employee LVN's at this facility, and the nurse was written up." She (ID#12) went on to say, the nurse (ID#15) refused to sign the counseling form because she did not believe she did anything wrong. No other disciplinary action was done. The facility did provide nursing competency testing on the subject on 05/5.6.8.9/2025 facility wide.