HospitalInspections.org

Based on observation, document review, and interview, it was determined that the Hospital failed to provide care in a safe setting and promote each patient's rights, by failing to ensure that patients were safe from ligature risks, suicidal attempts, and failing to follow the process of reporting and investigating an allegation of abuse. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include;

1. The Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the four (4) behavioral health units (2 North, 2 South, 3 North and 3 South) were free from ligature risks. See deficiency - A-0144A.

2. The Hospital failed to ensure that the psychiatrist was notified and patient's level of observation was increased after a suicidal attempt. See deficiency -A-0144B.

3. The Hospital failed to follow the process for reporting and investigating allegation of an abuse, to ensure patient was free from abuse or harassment. See deficiency - A-0145

An Immediate Jeopardy (IJ) was identified on 06/14/2023, due to the Hospital's failure to ensure patient rooms on the 4 behavioral health units were free from ligature risks, at 42 CFR 482.13, Patient Rights. The IJ was announced on 06/15/2023 at 2:30 PM, during a meeting with the Chief Operating Officer, Director of Plant Operations, Director of Performance Improvement and Risk Management, and the Director of Nursing. The IJ related to ligature risks at 42 CFR 482.13, Patient Rights, was removed by the survey exit date of 06/22/2023.

In addition, an immediate jeopardy (IJ) began on 06/8/2023, due to the Hospital's failure to ensure that the psychiatrist was notified and monitoring level was increased for a patient following a suicide attempt. The IJ was identified on 06/21/2023 at 42 CFR 482.13, Patient Rights, and was announced on 06/22/2023 at 11:30 AM, during a meeting with the Chief Operating Officer, Director of Performance Improvement and Risk Management, and the Director of Nursing. The IJ was not removed by the survey exit date of 06/22/2023.

A. Based on document review, observation, and interview, it was determined that for 4 of 4 Behavioral Health Units, the Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the behavioral health units were free from ligature risks. This has the potential to affect the current or future patients on suicide precautions admitted to the Hospital.

Findings include:

1. The Hospital's policy titled, "Rights of Recipients" dated 03/2023, was reviewed and indicated, "...recognizes that patients have a fundamental right to considerate care that safeguards their personal dignity to be free from abuse, neglect, or exploitation ...meeting the patient's care needs and preferences ..."

2. The Hospital's "Ligature Risk Assessments" for the 4 Behavioral Health units, were completed on 02/2021 and 02/2023. The ligature risk elements/categories, did not identify toilet seats in the patient bathrooms as ligature risks.

3. The Hospital's "Milieu Supervisor Environmental Rounds" tool for all the 4 behavioral health units, did not include, toilet seats as ligature risk.

4. On 06/14/2023 between 10:00 AM - 11:40 AM, an observational tour of the 3 North - Adolescent Boys and Girls Psychiatric Unit was conducted. The Adolescent Unit (AU) had a capacity of forty-four (44) beds with current census of 35 patients. During the tour, a ligature risk was identified in patient bathrooms. Out of the 20 patient rooms, that had one bathroom each, the toilet had a moveable (u-shaped) seat, that could be used as a ligature point. The hinge of the toilet seat was also raised at least 1 centimeter above the base of the toilet bowl which created a gap that could be used as a ligature point.

- Between 11:45 AM-12:15 PM, tours of the 3 additional behavioral health units (2 South, 2 North, and 3 South), were conducted. The same ligature risk pertaining to the toilet seats in the patients' bathrooms were identified on these units as well, as each unit had one toilet in each quite room on each unit, total of 84 toilets in the hospital.

5. On 06/14/2023 at approximately 11:45 AM, an interview was conducted with the Director of Plant Operations (E #8) and Director of Nursing (E #9). Both E #8 and E #9 acknowledged that the toilet seats definitely poses a ligature risk and was not identified until the date. E #8 stated that the Facility had not identified toilet seats as ligature risk under their annual ligature risk assessments. E #9 stated that the only mitigation plan as of right now, is to have the staff do every 15 minutes rounds to monitor for ligature risks. E #9 stated that she was unsure how the ligature was not identified in the annual risk assessments.

6. On 06/14/2023 at approximately 1:15 PM, the findings were discussed with the Director of Performance Improvement and Risk Management (E #2). E #2 stated that the environment risk assessments are done annually. E #2 stated that toilet seats were not identified as ligature risks for the year 2021, and 2023. E #2 stated that they plan on working immediately with the Director of Plant Operations to quickly seal/caulking of all the toilet seats at the hinges that poses a ligature risk.

7. On 06/15/2023 at 2:00 PM, the Director of Performance Improvement and Risk Manager (E #2) was interviewed. E #2 stated that the daily environmental rounding tool by the Program Managers and the Milieu Supervisors did not include the assessment of toilet seats as ligature risks, and moving forward the rounding tool has be revised and will be used as part of environmental rounds.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #3) clinical record reviewed for suicide attempt, the Hospital failed to ensure that the psychiatrist was notified, and patient's level of observation was increased after Pt. #3 was found with a pair of pants tied around their neck.

Findings include:

1. The Hospital's policy titled, "Suicide and Self-Harm Prevention Plan" (revised 3/2023) was reviewed and required, " ... d. The Newly Identified Risk Assessment is completed in cases when potential suicide risk is newly identified after admission. e. Patients who continue, or begin, to present at high risk for suicidality and/or self-injurious behaviors are to continue on, or be evaluated for, changes in precautions or increased monitoring levels. 5) d. Staff are to maintain safe and therapeutic environment for all patients ... if they have made a serious suicide gesture/attempt while in the hospital, then the clinical team will initiate the "Suicide Risk Protocol." 7) Response: a. Staff member will, upon finding a patient who has attempted suicide or self-injury: Notify patient's attending psychiatrist, Administrator-on-Call, Director of Nursing, Risk Manager, Family/Guardian."

2. On 06/21/2023, at approximately 10:00 AM, Pt. #3's clinical record was reviewed, Pt #3 was admitted on 02/05/2023 to the 3N adolescent behavioral health unit with a diagnosis of bipolar disorder. Pt. #3 was on suicidal and assault/homicidal precautions, requiring every-15- minute checks. Pt. #3's clinical record included the following:

-Pt #3's psychiatric evaluation and assessment, dated 02/06/2023 at 10:57 AM, included, " ...presenting with symptoms of suicidal ideation, aggression and self-harming ...reported that the school nurse made her upset and wanted to kill the nurse and herself ...is on multiple medications ...Goals of treatment: improve coping skills, improve symptoms of aggression, improve suicidal ideation ..."

-The multidisciplinary progress note, (entered by RN/E #22), dated 06/08/2023 at 9:58 PM, included, "Patient [Pt. #3] attempt SI [suicide] by strangling herself with a pair of pants she had in her room ...staff members jumped in ASAP [as soon as possible] and removed clothing from patient. Patient looked over no injuries observed. Patient states that she was triggered and that the floor was just too much for her. All parties notified and staff members were told to do more rounds on this patient." The clinical record did not indicate who was notified or the frequency of rounding. The Psychiatrist on call was sent a text message, however there was no documentation that the Psychiatrist returned the text or any other attempts made to contact the Psychiatrist.

-There was no change in level of safety precautions for Pt #3 after the suicide attempt on 06/08/2023 at 9:58 PM.

-The house physician's medical consultation note, dated 06/09/2023 at 11:52 AM, (greater than 12 hours after suicide attempt), included, "Assessment: Attempted SI - by trying to strangulate herself. No bruises visible. Plans/Recommendations: Pt. Education and reassurance. No new orders."

-The Mental Health Nurse Practitioner's (E #21) psychiatric progress note, dated 06/09/2023 at 11:38 AM (greater than 12 hours after suicide attempt), included, "Patient (Pt. #3) seen, chart reviewed. She attempted to strangle herself last night with a T-shirt she was observed by staff doing this ... Suicidality: Patient unable to contract for safety ...Thoughts: Patient is having suicidal thoughts self-harm by strangling last night ...Homicidal: Patient is unable to contract for safety ...Homicidal Thoughts: Yes -physical altercation with staff yesterday ..." The note did not include orders for an increase in observation level for Pt #3.

3. On 06/21/2023 at 10:10 AM, the Mental Health Nurse Practitioner (E #21) was interviewed. E #21 stated that he was not notified about the patient's suicidal attempt until the next day. E #21 stated that they should have implemented a much more vigilant monitoring of the patient after the suicidal attempt. E #21 stated that he was not the on-call psychiatrist. E #21 stated that they could have obtained a one-to-one sitter at the bedside or every 5 minutes monitoring.

4. On 06/21/2023 at 11:30 AM, the Nurse Manager (E #7) was interviewed. E #7 stated that there is no documentation of nursing assessment during the night shift after the patient's suicidal attempt. E #7 stated that they should have made a clinical judgement to have a sitter at the bedside or initiated a higher level of observation and notified the nursing supervisor immediately.

5. On 06/22/2023 at 10:40 AM, a telephone interview was conducted with the Registered Nurse (E #22) who witnessed Pt. #3's suicide attempt. E #22 stated that he went to the patient's room and noticed a towel, or pants, does not recall what it was tied tightly round her neck. E #22 stated that a code yellow was called, and all staff tried to remove the cloth from around Pt #3's neck and patient started crying. E #22 stated that he sent text message to all the appropriate staff. Upon asking who the appropriate staff were, E #22 stated he does not recall who he sent the text messages to. E #22 stated that he did not receive any orders from any physician for change in observation of patient or to place a sitter at the bedside after the suicidal attempt. E #22 stated that it is not within his discretion to make a clinical judgement as a nurse to increase level of observation or place a sitter with the patient. E #22 stated that he made an incident report and completed his shift at 11:30 PM on 6/8/2023.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #1) clinical records reviewed related to abuse, the Hospital failed to follow the process for reporting and investigating allegation an allegation of abuse, to ensure patient was free from abuse or harassment.

Findings include:

1. On 06/14/2023, the Hospital's policy titled, "Incident Reporting Process" (revised 2/23) was reviewed and included, "B. Incidents expected to be reported via the IR/Incident Reporting Process constitute any of the following Incident types ... Physical Confrontation ... V. Procedure: 1. Ensure timely and accurate reporting, and data entry of all incidents ... 4. Conduct follow up and investigation to ensure that appropriate actions are taken to prevent further incident/injury and/or reoccurrence. 5. Notify designated Risk Manager."

2. On 06/14/2023, the clinical record of Pt. #1 was reviewed. Pt #1 was admitted to the Hospital's 3-North female adolescent unit on 05/31/2023, with a diagnosis of disruptive mood dysregulation and was discharged on 06/08/2023. The clinical record included the following:

-Social Services Progress/Treatment Note, dated 06/06/2023 at 12:30 PM, included, '(Pt. #1) reported a person with dreads brought girls into her room and said, "I'll give you guys 2-minutes to fight, and I do this with boys too.' This incident occurred on 06/03/23, (Pt.#1) reported the male staff with dreads let (name of Pt. #2) in her room hit her."

3. On 06/09/2023, an Incident Report form, dated 06/09/2023, was reviewed and included, "Pt (patient/Pt. #1) mother called to complain that staff member brought 3 girls to the patient's room door and stated, 'I'm going to let you all fight it out like I do on the boys side'."

4. On 06/14/2023, at approximately 1:35 PM, an interview was conducted with the Social Worker (SW/E #10). E #10 stated that E #10 did not report (Pt. #1's) allegation of abuse from another patient (Pt. #2). E #10 stated that she intended to report this allegation, however it was a very chaotic day and E #10 forgot to file the report in the IR system. E #10 stated that by not reporting this type of incident, there is a potential of reoccurrence and injury to the patient.

5. On 06/14/2023, at approximately 3:15 PM, an interview was conducted with the Director of Quality of Risk (E #2). E #2 stated that once staff is made aware of any form of abuse, they should report the allegation to their Supervisor and/or Risk Management immediately in order to conduct an investigation and ensure a safe setting. E #2 stated that once the patient's (Pt. #1's) mother filed a grievance, an investigation was conducted. (Documentation confirmed an investigation was conducted immediately following receipt of grievance on 6/9/2023.)