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Based on document review, observation, and interview, it was determined that for 2 of 2 restrooms on the 3 West BHU (Behavioral Health Unit), the Hospital failed to protect and promote each patient's rights by ensuring a safe environment. This potentially placed all current and future suicidal patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not met.

Findings include:

1. The Hospital failed to ensure care was provided in a safe setting by maintaining safety interventions for the ligature risks identified in the patient restrooms on the Behavioral Health Unit. (A-0144)


The Immediate Jeopardy (IJ) was due to the Hospital's failure to ensure for ligature risks identified in the patient restrooms on the 3 West Behavioral Health Unit, that safety interventions were maintained for patients to be free from risk of causing self-harm or injury; and was identified on 12/24/2020 at 42 CFR 482.13, Patient Rights. The IJ for tag A-0144, was announced on 12/24/2020 at 12:30 PM, during a meeting with the Chief Executive Officer (E #16), Chief Clinical Officer (E #1), Director of Behavioral Health (E #2), and Assistant Administrator (E #17). The IJ was removed by the survey exit date of 12/24/2020.

The IJ was removed on 12/24/2020, based on interview and document review as follows:

1. On 12/24/2020, at approximately 1:30 PM, an interview was conducted with the Chief Clinical Officer (E#1). E#1 stated that effective immediately staff are required to be present with the patient and in direct observation of patients while using the bathroom to monitor patient safety. E#1 stated that staff will be educated prior to the start of their next shift and will only be allowed to work on the unit after receiving this additional training. E#1 stated that audits will be conducted daily to ensure that staff are following the new protocol.

2. The Hospital's Policy (draft dated 12/2020) was reviewed and required, "...Direct Observation-Patient will be visualized by staff at all times. When patient is in stall, staff will visualize patient's feet and maintain ongoing verbal communication. When a patient is using the communal restroom staff will: a. A staff member will accompany the patient into the restroom for the purpose of direct observation of the patient when in the restroom. b. To preserve patient privacy, direct observation means that the patient's feet will be observed beneath the stall door at all times..."

3. Review of the Hospital's Plan of Action included an in-service sign-in sheet for "Monitoring of Patient Bathrooms" which indicated completion by all staff on duty on 12/24/2020. The plan also included a form to be used for daily audits of bathroom monitoring.

Based on document review, observation, and interview, it was determined that for 2 of 2 restrooms on the 3 West Behavioral Health Unit, the Hospital failed to ensure care was provided in a safe setting by maintaining safety interventions for the ligature risks identified in the patient restrooms. This has the potential to affect the safety of the 8 psychiatric patients on census as of 12/23/2020, of which six (6) patients were on suicide precautions, and any future psychiatric patients who become suicidal.

Findings include:

1. On 12/23/2020 between 10:40 AM to 11:40 AM, an observational tour of the 3 West Adult Psychiatric Unit was conducted. The unit consisted of 11 patient rooms, which did not have private restrooms. The unit had 1 common restroom for men and 1 common restroom for women. Each restroom was locked when not in use and had two toilets and two showers each. A patient (Pt. #11), who was on suicide precautions, was using the common women's restroom with the door closed, while a male staff was standing outside the restroom. The women's restroom contained the following ligature risks:

- 1 of 2 toilet stalls had an open protruding door handle, creating a potential anchor point through which a ligature could be threaded.
- 2 of 2 toilet stalls had protruding lock latches, creating anchor points for hanging.
- The stalls had an approximate 5-inch wide (1-centimeter thick) post reaching from the top of the stall up to the ceiling that allowed for a tying point of a ligature for hanging.
- The same ligature points were identified in 1 of 1 men's restroom.
- There were no other bathrooms available for the patients to use.

2. The Hospital's Ligature/Self-Harm Risk Assessment, dated 11/2018, and completed by the Director of Compliance Strategies (Z#1- whom is from an outside consulting company) in November 2018 was reviewed on 12/23/2020, and indicated that the ligature risks in the restroom (stall handles, latches, and walls) were identified and included an intervention to have "direct observation" of patients when occupying the restrooms.

3. During the survey the open records of: Pt #3, Pt #9, Pt #11, Pt #12, Pt #13, and Pt #14 were reviewed. Pt #3, Pt #9, Pt #11, Pt #12, Pt #13, and Pt #14 were on suicide precautions as of 12/23/2020

4. An interview was conducted with the Milieu Manager (E#15) on 12/23/2020, at approximately 1:40 PM. E#15 stated that the restrooms are kept locked when not in use and are opened only when a patient needs to use the restroom. E#15 stated that if the staff member is of the opposite sex as the patient, the staff member will wait outside the bathroom and periodically knock on the door every 3 minutes to make sure the patient is still responding. E#15 stated that the stall handles, latches, and posts could be used as ligature anchor points for suicidal patients. E#15 stated that the staff standing outside do not go into the bathroom to visually look at the patient unless the patient has physician orders for 1:1 (one staff within close proximity to one patient at all times) monitoring or do not respond when staff knock on the door. E # 15 confirmed that staff members of the opposite sex as the patient, waiting outside the bathrooms, does occur.

5. A telephone interview was conducted with Z#1 on 12/23/2020, at approximately 2:30 PM. Z#1 stated that the stall latches, locks and walls were identified as potential ligature points. Z#1 stated that if these ligature points are not removed/replaced, staff are required to have "direct observation within the space of the patient, meaning staff have to be in the room to see the stall and have visuals of the patient's feet." Z#1 stated that the expectation of direct observation applies to all patients using the restroom, not just patients who are on 1:1 monitoring.

6. An interview was conducted with the Director of Behavioral Health (E#2) on 12/23/2020 at 3:30 PM. E#2 stated that it was not to E#2's understanding that staff needed to be inside the bathroom with the patient. E#2 stated that staff will need to be re-trained to ensure that they are directly monitoring the patients while in the restrooms. On 12/24/2020, at approximately 9:00 AM, E#2 stated that there were no audits conducted of patients for bathroom monitoring and that the Hospital does not have a policy on direct observation of patients while using the restrooms.

Based on document review and interview, it was determined that for 3 of 3 patients' (Pts. #5, Pt. #6, and Pt. #7) clinical records reviewed regarding use of violent behavioral restraints, the Hospital failed to ensure that the use of restraints were in accordance with a physician's order, as required.

Findings include:

1. The Hospital's policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (6/2020) was reviewed and included, "...Violent Behavior Restraints... Orders must include: ... type of restraint to be used..."

2. The clinical record of Pt. #5 was reviewed on 12/23/2020. Pt. #5 was admitted on 7/1/2020 with a diagnosis of schizoaffective disorder (mental disorder). The clinical record indicated that Pt. #5 was in a 4-point (both wrists and legs) locked restraints on 7/1/2020 from 7:00 PM through 9:30 PM. However, the physician order, dated 7/1/2020, did not include the type of restraints to be used.

3. The clinical record of Pt. #6 was reviewed on 12/23/2020. Pt. #6 was admitted on 8/19/2020 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #6 was in a 4-point locked restraints on 8/22/2020 from approximately 10:00 PM through 11:45 PM. However, the physician's order, dated 8/22/2020, did not include the type of restraints to be used.

4. The clinical record of Pt. #7 was reviewed on 12/23/2020. Pt. #7 was admitted on 10/21/2020 with a diagnosis of mood disorder. The clinical record indicated that Pt. #7 was in a 4-point locked restraints on 10/27/2020 from 10:20 AM through 10:50 AM. However, the physician's order, dated 10/27/2020, did not include the type of restraints to be used.

5. During an interview with E #3 (Registered Nurse) on 12/23/2020, at approximately 11:30 AM, E #3 stated that the restraint order form does not have a space to indicate the type of restraints used. E #3 stated, "We only use 4-point Velcro restraints on the behavioral health unit."