South Florida State Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 33162 Based on review of the Hospital’s Policies and Procedures, video observation, staff interview, and record review, the Hospital failed to ensure adequate supervision of nursing staff to ensure they respond appropriately to emergencies. This affected 1 of 4 sampled patients (Patient #3), who was on a puree diet due to choking risk but ate solid foods from the trash after a meal, was observed to be choking and the nurse gave him back slaps before leaving him to get water; who then collapsed on the floor 2 minutes later and reached towards his throat; after which the nurse propped him up and poured water in his mouth before further back slaps and initiating the Heimlich maneuver; and once the patient became unconscious, staff failed to start CPR (cardiopulmonary resuscitation) or connect him to an AED (Automatic Defibrillator Device), with no evidence of checking pulse or respirations despite observed cyanosis, instead doing abdominal thrusts for 6 minutes until EMS arrived to find the patient in cardiac arrest and not breathing. The inability to respond appropriately to emergencies places all patients in the hospital at risk. The findings included: The Hospital’s Policy and Procedures titled PC 300-19 Medical Emergencies STAT, effective 10/12/23, reviewed 3/9/26 documents, in relevant parts, “The procedure outlined below will be followed to ensure the provision of effective intervention for persons experiencing emergency medical problems, in order to prevent any further complications or serious injury. 5. Procedure 5.1 Discovery and Notification. When a staff member discovers a person who appears to require medical attention, he or she will first determine responsiveness. 5.1.1. If the person is unresponsive, the staff member will: - Assess airway, breathing and circulation (ABC) - Call for help; call 911 as indicated - ANY STAFF MEMBER MAY CALL 911 - Initiate CPR if no pulse - utilize the AED, if indicated, and once it arrives to the scene. 5.1.2. If the person is responsive, but appears to be in medical distress, the staff member will call for help. 5.1.3. Once a second staff member is alerted, he or she will notify the Receptionist/Security Officer (when receptionist is not available) of a Medical STAT situation. This is done by dialing “6” from the nearest phone. The nature of the emergency (if known) and the location of the victim will be communicated to the Receptionist/ Security Officer. [ ...] 5.2. Nursing/Medical Staff/Social Services Responsibilities 5.2.1. All medical staff will respond to a medical STAT. 5.2.2. The Nursing Supervisor/DON will always respond to a Medical Stat and will bring the Medical Stat form to the scene. 5.2.3. The Nursing Supervisor will document on the Medical Stat form all vital signs taken, as well as any other medical treatment provided (medication administration, oxygen applied, blood glucose levels). 5.2.4. Staff from the nearest 2 units will bring the Emergency Kit, AED, Oxygen and the glucometer to the Medical Stat site ...” Patient #3 was admitted to the psychiatric hospital on 02/24/20 with a mental health diagnosis and remained in the hospital on involuntary status by court order. Patient #3’s Nutritional Assessment on 11/24/25 documented he had some chewing/swallowing difficulties and was on a puree diet. Further review of Patient #3’s record confirmed active orders for a puree diet as of his choking emergency on 12/20/25. Review of video from the Las Olas C-wing camera overlooking the C-wing day room and hallway beginning 12/20/25 at 6:40 PM reveals the following: There is no separation between the day room and hallway as this is an open area. At 6:40 PM, Patient #3 was seated at a table in the day room being fed food from a tray that appeared consistent with a puree diet by Mental Health Tech (MHT) A. After finishing his meal, Patient #3 got up and stayed in the area. At 6:42 PM, Registered Nurse (RN) E entered the C-wing, passing Patient #3, and stood in the hallway to the right facing the day room as another patient came out of a room to the right carrying a tray with several pieces of solid food, crossing in front of Patient #3 before Patient #3 sat in a chair to the right and RN E turned and walked away from the camera down the C-wing hall. The patient with solid foods on his tray talked with MHT A as they both gestured at his tray before he dumped the food in a paper trash bag by the doors to the lobby at 6:44 PM. At 6:44 PM, Licensed Practical Nurse (LPN) D entered and left the C-wing after several seconds and RN E and MHT A left the C-wing at 6:44:40 (hours:minutes:seconds), leaving no staff on that wing and the trash with solid foods behind. Patient #3 immediately stood up and headed towards the trash. At 6:44:49 PM, MHT B entered the wing and went to a chair on the right, her back to Patient #3 as he rifled through the trash, and sat down looking in his direction as he hunched over the trash, removed something and took a bite of it, then walked with the object sticking out of his mouth to sit next to her at 6:45:30 PM, another object in hand, and visibly chewing. MHT B looked towards the doors and back at Patient #3 before standing up and walking off camera towards the lobby at 6:45:49 PM. Patient #3 got up as soon as she left camera view, walked across the room and put the palm-sized object in his hand near the TV, returned and sat back down as MHT B re-entered the wing at 6:46:15 PM. LPN D entered the C-wing at 6:46:22 PM, looked around and left at 6:46:26 PM. MHT B looked in the trash, went to the table, then faced Patient #3 and walked towards him as he continued visibly chewing before she was interrupted by another patient. At 6:47:11 PM Charge Nurse, RN C walked onto the C-wing and approached Patient #3 as MHT B gestured in his direction. At 6:47:31 PM, Patient #3 stood up briskly and MHT B moved away. Patient #3 looked at RN C when suddenly, at 6:47:38 PM, Patient #3 faced forward, eyes wide and seeming to gasp or attempt to cough with his head forward, mouth open, swaying as working his throat and appearing in distress. At 6:47:43 PM, RN C stepped forward and, although his back was to the camera, appeared to place his left hand to Patient #3’s chest and his right arm made jerking thumping motions at his back approximately 6 times, before RN C leaned left to look at Patient #3’s face and stepped back at 6:47:54 PM. At 6:48:02 PM, RN C turned towards the camera, walked towards the lobby with relaxed pace, and left the C-wing at 6:48:09 PM. Patient #3 sat back down at 6:48:10 PM. MHT B picked up the 2 trash bags and left the C-wing at 6:48:16 PM, leaving no staff on the C-wing. At 6:48:19 PM, Patient #3 leaned forward and tried to stand up, using his arms, but sank back into the chair 7 seconds later. Patient #3 leaned forward and tried to get up again at 6:48:29 PM, this time standing with effort at 6:48:35 PM, and walked towards the lobby. Review of video from the Las Olas lobby camera, mounted inside doors to the outside grounds and overlooking the lobby, nursing station and part of the B-wing, from 12/20/25 beginning at 6:40 PM reveals the following: At 6:48:17 PM, Charge Nurse/RN C entered the lobby from the C-wing (to the right) and walked with no obvious haste to the Nutrition Room (to the right of and across from the nursing station door in front of the B-wing) which he entered at 6:48:36 PM. MHT B entered the lobby from the C-wing and went in front of the nursing station towards the A-wing (to the left) carrying two paper trash bags. At 6:48:50 PM, Patient #3 entered the lobby from the C-wing and walked directly to the lobby bathroom closest to the outside doors (far left camera view) and entered but left the bathroom door open at 6:49:03 PM. At 6:49:06 PM, RN C walked out of the Nutrition Room with a cup in hand and turned towards the C-wing. Another patient closed the bathroom door after Patient #3. At 6:49:40 PM, Patient #3 exited the bathroom, took several steps into the lobby, stopped, his legs bent and he dropped onto his back, before lying prone, arms out to his side, mouth opening and closing, upper face a deep reddish-purple, with his abdomen (but not chest) visibly rising and falling with laborious attempts to breathe by 6:50:16 PM. Patient #3 raised his left hand towards his throat, then his right hand, which is a universal sign of choking. Meanwhile, RN C entered the lobby, cup still in hand, and walked to Patient #3 on the floor as RN E came from the nursing station. At 6:50:18 PM, RN E and RN C each grabbed an arm and pulled Patient #3 to sitting position. However, instead of initiating the Heimlich maneuver for choking, RN C brought the cup in his left hand towards Patient #3’s face as he pulled him up with his right and RN E propped him up with her leg behind his back. Patient #3 lowered his hands to the floor, arms bent and unable to support his weight as his torso lowered against RN E’s leg, as RN C tilted the cup to Patient #3’s mouth at 6:50:26, increasingly tilting the cup. RN C reached around and pressed on Patient #3 ‘s upper back as RN E pressed his back with her knee. At 6:50:39 PM, RN C back-slapped Patient #3 three times, jolting him forward, then put the cup to Patient #3’s mouth again at 6:50:41 PM. RN C repeatedly tilted the cup back to Patient #3’s mouth as he and RN E tried to keep his upper body up until at least 6:51:00 PM, then he passed the cup to RN E. At 6:51:20 PM LPN D approached and picked Patient #3 up by his arms around his torso, RN C stepped in and did abdominal thrusts from behind that lifted the patient, then stepped aside, after which Patient #3 swayed on his feet and LPN D stepped back in and did more abdominal thrusts before Patient #3’s legs folded. At 6:51:58 PM, RN E hurried towards the nursing station, cup in hand, as LPN D and RN C lowered Patient #3 to the floor on his back, his mouth open with small movements. At 6:52:05 LPN D did 2 strong two-hand abdominal thrusts before RN C put his hand on the pt’s now bare stomach and LPN D withdrew. RN C pressed his right hand on Patient #3’s stomach from the side, left hand behind the patient’s neck, as another patient who had been observing came and held the pt’s head. LPN D tried to move in with his hands together to do more two-hand abdominal thrusts, but RN C was bent over the pt, hand on pt’s stomach, and LPN D could not get in position. RN C continued rhythmically pressing Patient #3’s stomach from the side, then they repositioned the patient flat on the floor, extending his legs. Patient #3 moved one arm and his head no longer appeared red. At 6:54:18 PM, RN C and LPN D lifted and dragged Patient #3’s body to a chair and a blood pressure cuff was applied. At 6:55 PM two security officers, a Nursing Supervisor, and RN K from another unit entered the lobby from the grounds, as well as an evening nurse, RN J, arriving before her 7 PM shift. Patient #3 made spontaneous movements of his left arm, left leg, and head. The last visible voluntary movement by Patient #3 was movement of his head at 6:55:50 PM. At 6:56 PM, RN E brought a rolling oxygen tank with a clear bag, 2 more staff arrived to the unit, RN K removed an Ambu bag (used to deliver breaths to a person when they cannot breath for themselves) from the clear bag and approached RN E with it, then put the Ambu bag back in the bag, and RN E handed RN C an oxygen face mask which he placed on Patient #3’s face. At 6:57:02 PM Patient #3’s head slumped forward, oxygen mask on his face, although his color still appeared normal. Staff then moved Patient #3 to the floor, where he no longer had the oxygen mask in place. At 6:57:30 PM, RN K started rhythmic up and down motions over Patient #3, but staff blocked the view and it could not be seen if he did chest compressions or abdominal thrusts. RN C and RN E kneeled on opposite sides of Patient #3’s head and Supervisor F stood leaning over them and the patient. At 6:58:17 PM, Patient #3’s head was visible and his head and face were dark bluish-purple. At 6:58:41 PM, RN E brought a rolling “crash cart” near the patient and picked up the plastic bag containing the Ambu bag and hung it on the rolling oxygen tank. At 6:59:10 PM, RN K stopped compressions or thrusts, staff lifted Patient #3’s torso and RN K did abdominal thrusts with his arms around the pt. The back of Patient #3’s head and neck did not appear red or bluish, but normal at that time. At 6:59:53 staff laid Patient #3 back on the floor and at 7:00:27 RN C started pushing rhythmically on his stomach, stopped and appeared to yell angrily at a female staff who approached with his elbows out and hands on hips before throwing his hands up, then to kneel squarely over the patient and resume rhythmic motions evidenced by jerks of the patient’s legs and feet, although the view of his torso was blocked. At 7:01:00 PM, RN C stopped and Patient #3’s face was seen to be bluish purple and bare as LPN D took over; RN C stepped back in at 7:01:20 PM, causing LPN D to move back, and kneeled down and resumed thrusts; RN C stopped again at 7:01:56 PM whereupon LPN D took over; RN C went back to Patient #3 at 7:01:19 PM and took over thrusts; RN C stopped again at 7:01:55 PM and walked away and RN J started thrusts from a bent standing/squatting position over Patient #3; RN C pushed RN J aside at 7:02:22 PM and resumed thrusts or compressions; RN C stood up and stepped back at 7:22:42 PM as a Fire Rescue personnel arrived, resumed when Fire Rescue looked at him and motioned to the patient, and stopped when Fire Rescue tapped his shoulder at 7:03:00 PM. Fire Rescue assumed care and worked to clear and establish an airway as chest compressions were started, much higher up on the patient than was seen before, and AED (Automatic External Defibrillator) pads applied to the chest. The hospital’s crash cart remained unopened and Ambu bag still hung on the wheeled oxygen carrier. At 7:16 PM Patient #3 was wheeled out by stretcher During video review and interview with the Administrator, a Doctor of Nursing Practice, on 03/17/26 starting at 3:45 PM, the Administrator stated he watched the video himself many times and, having been an ICU nurse for 12 years, he felt good that they did everything right for this patient; when asked why the nurse gave water to Patient #3 after he passed out, he stated because the patient had asked the nurse for water earlier. The Administrator did not acknowledge the risk of water going to the lungs and/or laryngospasm from giving water to a choking victim who could not breathe adequately (let alone swallow), as evidenced by the video observations and his passing out on the floor with face purple. During video review and interview with the Las Olas Unit Manager G on 03/18/26 at 10:42 AM, Unit Manager G stated she and Risk Manager, Staff H interviewed RN C about the incident; that he asked if everything was ok; and Unit Manager G told him the report was ok and from what she saw he tried everything to save the patient. During interview on 03/18/26 at 12:14 PM, Charge Nurse/RN C confirmed he remembered Patient #3’s choking on 12/20/25; stated he heard MHT B being loud and went to the C-wing where she said Patient #3 took food from the trash; that he asked Patient #3 why you do that and he did not answer and just said I need some water; that he was not coughing and not in any distress or he would not have gone to get him water; that if he was in distress RN C would have asked someone else to go get the water; RN C denied patting or hitting Ocana’s back, even when told this was seen on video, but stated Patient #3 was ok and he was just talking to him; that he went and came back with the water but Patient #3 was not there so he turned around and looked for him; that RN C saw Patient #3 walking from the bathroom in the lobby, then he went to the floor; that he thought something happened, that maybe he’d choked or something; that he and LPN D tried to sit him up by the arms and he asked RN E to call 911; that RN C tried to do CPR and denied trying to give him water, saying there was no water until surveyor told him this was seen on video; when asked what happens when you give a choking person water, he responded it makes it go down; stated he tried to do the Heimlich maneuver and then put Patient #3 in the chair; that Patient #3 was breathing and he was not coughing; did not answer when asked why he would do the Heimlich if the patient was breathing; denied remembering when asked about the color of the patient; when asked if Patient #3’s face was red or purple responded he was not pale; when asked why he moved the patient to the chair he said he had to get a blood pressure and vital signs; when asked why they moved him to the floor he said it was because they called the “Medical STAT” and there’s going to be more people all around and “to manage him to get him back;” that Patient #3 still had a pulse but he wanted to get that out of his throat; and when asked for the reason he started CPR stated it was to try to get whatever was in, out. During further interview on 03/18/26 at 12:45 PM, RN C stated they were trying to keep Patient #3 ok until “911” could get there and try to get something out; that they were not doing CPR but to see if they could get anything out; that Patient #3 still had a pulse and was breathing; that when 911 was called Patient #3 still had a pulse and when “911” arrived he still had a pulse but he was not sure if he was breathing when “911” arrived; that they put Patient #3 on the floor after the chair and were not doing CPR but were pushing to try to push it (the throat obstruction) up to get it out; that when Patient #3 was first on the floor in the middle of the lobby RN C called his name but he wasn’t speaking; that he doesn’t think the water went down but Patient #3 did not swallow; and that “911” got a big piece of chicken out. During interview on 03/18/26 at 11:46 AM, LPN D confirmed he remembered Patient #3 choking; that he saw the patient sitting on the floor in the lobby; that this patient had trouble to walk but for him to collapse, he knew something had to be wrong; that Patient #3’s face was red and then it was purple; that they have told the patient so many times not to take food out of the trash; that when he got to him Patient #3 was just lying there with his eyes open, not doing anything, no response to sternal rub, and he wasn’t breathing; denied seeing the patient given water; that LPN D thought Patient #3 was choking and he picked the patient up to do the Heimlich maneuver; that at one point he thought they got the blockage out because his color came back and he moved a little bit so they took him to the chair to get vital signs and then he became purple again; that he thinks he was conscious in the chair but then he changed again; and paramedics took out two huge chunks of chicken that had not been chewed. During interview on 03/19/26 at 10:50 AM, RN K stated he had responded from another unit and arrived to find Patient #3 in a chair in the lobby; that he felt a pulse on his neck and wrist when he came up to him; that he didn’t know if Patient #3 was breathing when he arrived but staff were shaking him and trying to get him to respond; that he was unresponsive, so RN K suggested to move him to the floor; that Patient #3 was turning red and someone yelled get the oxygen; that RN K started abdominal thrusts and just did abdominal thrusts; that another nurse later checked the wrist and didn’t say anything; that he never heard out loud that there was or was no pulse; that RN C was sitting on him doing abdominal thrusts, not CPR, and RN K traded off with RN C; that the color in Patient #3’s face was red and that never got better; that EMS (Fire Rescue) took over and did CPR and got a piece of meat out; and he lef the area when they looked like they were getting ready to intubate. During interview on 03/19/26 at 11:23 AM, RN E reported after mealtime that day she heard RN C calling for Patient #3 in the C-wing before she saw Patient #3 standing in the lobby and going onto the floor; that RN C tried to give Patient #3 water but he couldn’t take the water and was not responding; that he was not drinking the water when put to his lips but she was not sure if it ran out of his mouth or went down; that Patient #3 was breathing, but with difficulty; that RN E said I think he’s choking and ran to the nursing station with the water cup and called a “Medical STAT” and, seconds later, called 911; that she thinks they tried to sit Patient #3 up and RN C and LPN D did the Heimlich maneuver; that no one came and she had to call 911 again; that she brought oxygen and the crash cart; and that she was not sure if they were doing abdominal thrusts or CPR when EMS arrived. Review of Patient #3’s Medical STAT Worksheet, dated 12/20/25 documents the Medical STAT and 911 were called at 7:03 PM and the type of emergency as “Respiratory;” that the patient was slumped in a chair and checked for responsiveness but not whether he responded and the Glasgow Coma Scale was not done; that breathing was “shallow” but no rate; that Patient #3 was cyanotic and no evidence of circulation check; that pupils were sluggish and dilated; no vital signs; no response to “AED applied if P/S (Person Served or patient) unresponsive”; that Patient #3 was put on the floor to facilitate abdominal thrusts and 2 staff took turns until “911” arrived at 7:12 PM; for CPR (cardiopulmonary resuscitation) initiated, the response “yes Heimlich,” although cardiopulmonary resuscitation was not started until Fire Rescue arrived and started it Patient #3’s Fire Rescue record documents “Cardiac arrest prior to EMS arrival. Cardiac arrest etiology: respiratory/asphyxia. Estimated time of arrest: 2 to 4 minutes;” primary impression “cardiac arrest” and secondary impression “foreign body in trachea;” patient’s level of distress “severe;” signs and symptoms “cardiac arrest (primary), apnea, asystole, choking - food, foreign body in respiratory tract, and ventricular fibrillation;” treatment prior to arrival “Heimlich maneuver” and patient response was unchanged, unsuccessful; that Fire Rescue initiated chest compressions and removed several pieces of chicken from the patient’s trachea; that the initial heart rhythm was asystole (no activity) and the patient was taken to the hospital with further interventions by Fire Rescue. Patient #3’s “DAP” Note/Event entry on 12/20/25 at 8:58 PM RN C documents when RN C saw Patient #3 on the C wing, he was responsive, talking with nothing in his mouth and asking for water, that while RN C went to get him water Patient #3 went to the bathroom in front of the nursing station and was found on the floor in the lobby awake with minimal verbal response and moving; that he and LPN D started the Heimlich maneuver while a Medical STAT and 911 were called; that the patient was placed on the floor and staff performed abdominal thrusts for about 10 to 12 minutes before Paramedics came; that when Paramedics came Patient #3 was unresponsive with pulse, and he was intubated and transported to (an acute care) hospital. Per the acute care hospital record, Patient #3’s CT of the brain on 12/20/26 after arrival showed “diffuse severe loss of gray-white matter differentiation concerning for hypoxic ischemic encephalopathy (brain injury caused by lack of blood flow to the brain)” and “diffuse cerebral edema (widespread swelling of the brain)” and Patient #3 was determined brain dead on 12/23/25.”