St Josephs Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42154 Based on review of policies, medical records, and staff interviews, the facility failed to provide care in a safe setting for 1 of 1 patient deaths reviewed (Patient #1), which resulted in the patient’s death. Findings included: Review of the policy and procedure title, “Emergency Treatment Orders (ETO)”, #300.177.05, revision 05/2026 ...The use of an ETO constitutes and is documented as a restraint... Policy and procedure titled, “Code Grey initiation of Code Grey Team”, #SJH-SEC-502.9, reviewed 04/2026 ... When a patient ...is observed by a team member demonstrating behavior creating a perceived or real threat of danger the team member ...follow the acronym P-be proactive and notice early warning signs, R- respond, restrict and contain, E- assess the environment, V- Use verbal intervention and de-escalation techniques. E- explain limits and consequences, N- Negotiated whenever possible, T- Takedown and restrain, when necessary ... Review of Patient #1’s medical record showed that on 05/05/2026 at 12:48 AM, an ETO consisting of Benadryl 25 mg, Ativan 2 mg, and Haldol 20 mg was administered intramuscularly (injection in the muscle tissue) for agitation. At 12:50 AM, a Code Grey (manpower for assistance) was called, and the patient was physically restrained on the floor. Twenty-six minutes after the ETO was administered, a Rapid Response was called to the patient ’ s room due to clinical deterioration. Thirty-six minutes after the ETO, a Code Blue (cardiac or respiratory arrest requiring immediate resuscitation) was initiated. Forty minutes after the ETO, chest compressions were started. Patient #1 was pronounced deceased on 05/05/2026 at 2:00 AM with no return of circulation. During an interview on 06/09/2026 at 10:18 AM, Staff O, security stated that a security officer yelled out the door, “Hey, can someone come check him?” During an interview on 06/09/2026 at 10:02 AM, Staff P, security stated that after the patient was secured, he noticed within a few seconds that something was wrong. He opened the door and yelled for a nurse to come check on the patient. He stated that no one entered the room until the Administrator on Duty (AOD) arrived a few minutes later. During an interview on 06/09/2026 at 10:46 AM, Staff Q, Registered Nurse (RN) stated that the team could not obtain an oxygen saturation reading because it was too low, and the patient was placed on oxygen. She stated that when the door was opened, a towel was draped over the patient ’ s face from earlier attempts to prevent spitting and biting, and that the AOD instructed staff to remove the towel to assess the patient’s face. During an interview on 06/09/2026 at 6:16 PM, Staff R, security stated that the patient was acting erratically and that nursing staff requested assistance in administering medication. He stated that the patient was walking around the room and sat in a chair when asked. After the nurse left the room, the patient began yelling and using profanities, then stood up and slapped a security officer. Staff R stated that security personnel took the patient to the ground and secured him. He reported that after a few minutes, he noticed the patient’s breathing changed and yelled out the door for someone to come check him, but no one responded. He yelled a second time, after which the AOD entered the room. Staff R stated, “He was no longer a threat because we had him secured to the ground. The nurses should have come in to check when we asked, more than once. They should have been there sooner, especially knowing his medical history.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 53733 Based on review of facility policies, review of video footage, medical records, and staff interviews, the facility failed to utilize less restrictive interventions prior to using restraint or seclusion for 1 (Patient #1) of 3 patients reviewed. Findings included: Review of facility policy titled “Code Grey Initiation of Code Grey Team” SJC-SEC-502.9, section 2, subsection a; “when a patient is observed by a team member demonstrating escalating behavior creating a perceived or real threat of danger the team member will V-use verbal intervention and de-escalation techniques” ... Review of facility policy “behavioral health collaborative and med/surg/tele collaborative” NCL0031a, restraints or seclusion are only used when less restrictive interventions are ineffective ...”Staff to consider alternative interventions prior to the initiation of restraints. Alternatives include; identify the root cause, meeting comfort or personal needs, food and fluids, reality orientation, use of diversion” ... Review of facility policy titled “Emergency Treatment Orders (ETO) 300.177.05 under title policy; “the use of an ETO constitutes and is documented as, a restraint”. Review of video footage (no audio) revealed the following: 12:33 a.m. - Patient #1 was observed knocking on the nurses ’ station door. The door opened, and a technician appeared to speak with the patient. 12:34 a.m. - Staff E walked to the door and appeared to speak with Patient #1. Patient #1 attempted to push the door open. Staff G and Staff E were observed pushing the door closed. 12:35 a.m. - Patient #1 returned to his room and threw a cup of fluid at the nurses ’ station window. 12:40 a.m. - A male security guard opened Patient #1 ’ s room door and entered. 12:41 a.m. - Patient #1 was standing in his room with what appeared to be a blanket draped over his shoulders. Patient #1 then sat in a chair 12:48 a.m. - Staff entered the room and administered the ETO. 12:50 a.m. - Clinical staff exited the room. Security personnel remained inside, and the door was closed. 1:04 a.m. - A stretcher was placed outside the room, and staff were observed in the room with a vital-sign machine. 1:08 a.m. - Staff brought a backboard and the stretcher into the room. Security personnel were observed exiting the room. 1:09 a.m. to 1:19 a.m. - Staff were observed entering and exiting the room repeatedly. 1:20 a.m. - A code cart was brought into the room. 1:21 a.m. to 2:00 a.m. - Staff continued entering and exiting the room. Security personnel remained outside the room. 2:03 a.m. - Staff exited the room with the vital-sign machine. Review of Patient #1’s medical record showed an admission date of 05/03/2026 with a diagnosis of schizophrenia (a chronic mental disorder that affects perception, thinking, and behavior). Patient #1 had a past medical history of acute respiratory failure, high cholesterol, high blood pressure, and morbid obesity (BMI (Body Mass Index) =40 or =35 with obesity-related conditions). According to a note documented by Staff E, the patient was described as aggressive and violent. The patient rushed to the nurses’ station door, pushed it open, and got halfway through. Staff secured the door closed, and the patient did not enter the nurses’ station. The patient then spit at the door, attempted to punch it several times, and threw a pitcher of juice at the nurses’ station window. At 12:35 AM staff called security. At 12:38 AM, the medical doctor (MD) was contacted and issued an Emergency Treatment Order (ETO) for 20 mg Haldol, 2 mg Ativan, and 25 mg Benadryl. Video monitoring showed the patient stepping onto a recliner in an attempt to damage or block the camera. The patient stuffed toilet paper into part of the camera and smeared spit on the lens. As security and unit staff entered the room, the patient directed attention toward a female security officer and the documenting staff member. The patient used racial slurs and stated he intended to physically harm staff. The ETO medications were administered at 12:48 AM in the right and left upper arms while the patient was seated in a recliner.No redness, swelling, warmth, or pain was noted at the injection sites. Three hospital security guards present to ensure safe administration for patient and staff. As staff re-entered the nurses’ station, the patient began fighting with the security officers. Unit staff left room, 3 security guards remained to ensure patient safety. A hospital-wide Code Gray (an emergency code used to signal a combative, aggressive, or violent person) was called at 12:50 AM. Security staff stated, ‘The patient is assaulting security guards; call the MD for discharge for arrest.’ The MD was called at 12:51 AM, and a discharge order was placed at 12:56 AM. Security guard observed running to get police officer, hospital house supervisor present, staff assessed vital signs. Pulse oximetry (a noninvasive, painless device used to quickly measure your heart rate and the oxygen saturation level in your blood; normal range 95%-100%) was difficult to obtain, with readings of 85-86 percent. Oxygen applied via nasal cannula. Rapid Response (when a patient shows early signs of clinical deterioration) called at 1:10 AM. Code Blue (a critical hospital emergency where a patient experiences cardiac or respiratory arrest, requiring immediate resuscitation by a specialized medical team) started at 1:20 AM. Patient #1 was pronounced deceased on 05/05/2026 at 2:00 AM. During an interview on 06/08/2026 at 9:37 a.m., Staff A, Accreditation and Regulatory Behavioral Health stated ’ They did not want to restrain him because he gets short of breath when lying flat. ’ During an interview on 06/08/2026 at 1:30 p.m., Staff C, Security stated when security first arrived on the unit, the door to Patient #1 ’ s room was closed, and when it was opened, the patient ’ was just sitting on the couch. ’ Staff C, Security further stated, ’ When I walked out, I saw the three officers holding the patient on the floor. ’ During an interview on 06/09/2026 at 8:03 a.m., Staff I, BHT stated the nurse told the patient, ’ In order for you to have Gatorade, I need to check your vital signs and blood sugar. ’ Staff I, BHT explained Patient #1 was seen throwing water at the nursing window. As a result, security was called as well as the doctor for medication. Staff I, BHT stated she was standing in the doorway and Patient #1 was sitting calmly when he yelled, ’ Don ’ t come near me or I will bust you up.’ Staff I, BHT further stated, ’ Maybe finding a way to de-escalate would have avoided this situation. During an interview on 06/09/2026 at 11:30 a.m., the Assistant Chief Medical Officer (ACMO) of Psychiatry stated, ’ There is a need for training with security on how to remove yourself so there isn ’ t an escalation of that behavior. Security arrived, and our nursing team was pushed out and taken over by security. ’ The ACMO also explained that in a situation where a violent patient wants something, food can be used to deescalate. The goal is to deescalate even if feels like staff are losing a battle and disclosed “this is not a bargain”. The one thing that could deescalate this behavior was not utilized but rather challenged. It was a “battle of wits”. The ACMO also explained that if he needed an ETO we will give it but “he was calm when he got it”.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 36678 Based on medical record review, interviews, and policy review, the hospital failed to identify an unresolved condition due to insufficient communication and documentation in the medical record for 1 (Patient #1) of 2 patients sampled, resulting in hospitalization at another hospital. Findings included: A review of the medical record for Patient #1 revealed a hospital visit on 10/2/25 for unresolved nausea, vomiting, and diarrhea. Patient #1 was admitted to observation for abdominal pain and pancreatitis, hypertensive urgency (elevated blood pressure), and fluid overload. Significant labs reflected hypomagnesia (low magnesium levels) and hypokalemia (low potassium levels), as well as elevated pancreatic enzymes (lipase). Patient #1 had a history of a clotting disorder (antiphosolipid antibody syndrome), hypertension (high blood pressure), obesity, and Lupus (an autoimmune disorder where the immune system attacks healthy cells and tissues, including organs, causing widespread inflammation). Orders included anticoagulation, I and O (intake and output) every eight hours, a clear liquid diet, and a GI (Gastroenterology) consult. Further review of the medical record reflected no documentation of intake or output after 10/3/25. The diet order was changed on 10/3/25 to full liquid. Gastroenterologist documented a progress note on 10/3/25 which reflected OK for regular diet. On 10/4/25 the Hospitalist progress note entered by Staff E, MD (Medical Doctor) reflected Patient #1 was tolerating the full liquid diet and had a normal BM (bowel movement) today, will consider advancing diet to low residue later today or in the morning. Review of physician’s orders reflected the diet orders were never changed. Review of the medication administration record revealed Patient #1 continued requiring antiemetics (medication for nausea and vomiting) throughout her stay, with only one documented episode of nausea and vomiting on 10/4/25, and continued with abdominal pain throughout her stay. Patient #1 refused po (by mouth) medications throughout most of her hospitalization. Documentation from nursing reflected a physician was notified on 10/3/25 and 10/4/25, with a request on 10/4/25 to change the potassium order to IV (intravenous). Review of the Discharge Summary entered by MD E, Hospitalist, dated 10/6/25 documented Patient #1 had been observed eating a sandwich the day before while still having a liquid diet order, and was discharged since she was tolerating a regular diet. (discharged in the early afternoon of 10/5/25). There was no nursing documentation reflecting this. Review of the medical record from an admission at another hospital, dated 10/6/25 revealed an emergency department (ED) arrival at 8:34 PM for abdominal pain, inability to tolerate anything by mouth including her medications, unresolved nausea, vomiting and diarrhea, and hypertension (blood pressure was 208/150 in the ED) with a head ache and blurred vision. Family reported she became unresponsive in the car on the way to the ED. A CT (Computed Tomography) scan of the abdomen and pelvis in the ED reflected small bowel loops with submucosal edema indicating acute infectious or inflammatory bowel disease. She was admitted for hypertensive emergency, unable to tolerate po (by mouth), intractable nausea/vomiting, acute diarrhea, acute abdominal pain, acute colitis (inflammation of the colon characterized by diarrhea, abdominal pain, and bleeding), and acute kidney injury. She furthermore suffered a seizure in the ED and was found to have bilateral subdural hematomas (a collection of blood in the brain and its outer covering), resulting in PRES (posterior reversible encephalopathy syndrome-brain swelling), and an ICU admission. She continued throughout her 11 day hospitalization to be unable to tolerate a diet or po medications until 10/14/25. On 10/17/25 after suffering from another seizure, she was transferred by helicopter to a higher level of care at another hospital for a neurosurgery evaluation. At 12:30 PM 11/24/25 PM during an interview with Staff A, Regulatory Manager, stated there was an order for I and O for Patient #1’s entire admission. It should have been documented, but it was not. At 1:01 PM on 11/24/25 PM during an interview with Staff B, Assistant Nurse Manager, stated if I and O is ordered by the physician then “we are supposed to document all intake and output.” At 1:15 PM on 11/24/25 PM during an interview with Staff C, RN (Registered Nurse) 3 North, stated an order for I and O means all output has to be documented. PCT’s (Patient Care Technicians) and nurses have to do it. All intake has to be documented, either by the nurse or PCT. “If I take the tray, I document it. If they have emesis, it has to be measured. We use a graduated cylinder. We document the size, consistency, and color of the stool. If the patient is refusing medication because they are nauseated or vomiting, then you document a comment and notify the doctor. If you give them something for nausea and vomiting and it does not help, you notify the doctor.” At 1:26 PM on 11/24/25 PM during an interview with Staff D, RN Charge 3 North, stated she doesn’t remember anyone reporting any refusals to take medications. Standard I and O order, you document the output and intake of food and fluids. Most of the time it is the techs. Meals and bathroom usage is techs. On 11/24/25 at 1:55 PM during an interview with Staff E, MD Hospitalist stated Patient #1 had pancreatitis. She was NPO for bowel and pancreas rest. The family was bringing food in from outside and it was making her stay complicated. You do not want any pancreatic enzymes. Food causes them to release. Nursing saw her having food brought in. She was eating and tolerating the diet. She was not vomiting. “I thought we advanced the diet. She acknowledged she ate outside food. A full liquid diet has some solids. She was refusing a lot of medications. She was refusing a lot of treatment modalities.” If she did not take the Lupus medication (hydroxychloroquine), the risks include blood clots, heart attack, and stroke. She was not getting out of bed. If you can eat then you can go home. That is the criteria for discharge for pancreatitis. She was dictating her own care. On 11/25/25 at 9:56 AM in an interview with the Director of Patient Services, stated the nurse needs to tell the charge nurse and make them aware the patient is refusing meds. If the doctor orders I and O’s every 4 hours for example, then the expectation is that every 4 hours there would be documented intake and output. The other expectation is that when they give report in shift change they go over the orders and review all that. The doctor is expected to put in his own orders. If they did not change the diet order in the computer and the nurse did not see the diet order change, she should have followed up with the physician. At 10:28 AM on 11/25/25 during an interview with the CMO (Chief Medical Officer), he stated the treatment for pancreatitis is bowel rest. If Patient #1 was tolerating po, then appropriate treatment is po medications. If Patient #1 was able to tolerate solids, then we should have changed the diet. They should have changed the diet 24 hours before discharge to see if she was tolerating it. A review of the policy, Assessment/Reassessment of (Adult) Patients, last review date, 7/25, revealed: Policy Reassessment The patient’s status is reassessed at regular intervals. Reassessment is triggered by changes in patient’s condition or needs, change in caregiver, and change request from patient family or physician and to determine the response to effectiveness of care and interventions. Departmental Assessment Guideline Summary Nursing 1. The RN is responsible for the initial assessment of patients. Other team members participate in data collection. 3. Reassessment is completed per department policy and as follows: e. Physician order g. As specified in clinical standards (Unit Standard) Inpatient Medical-Surgical/PCU/Telemetry The second assessment is a focused assessment, and includes ...I and O ... Review of the policy, Documentation: Nursing, dated 8/25, reflected: Policy: Vital signs, intake and output, assessments, interventions, and the patients response to the individualized plan of care are documented in the patient’s medical record. Unit and clinical standards determine the frequency of monitoring. Team members involved in the medical documentation process have a personal obligation to complete accurate documentation. Procedure: Assessment: Document diet type and percentages of meals and snacks consumed. Record intake and output. Review accuracy of shift totals. 24 hour totals are auto calculated.”