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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.614, PATIENT RIGHTS, was out of compliance.

C-2523 The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure suicidal patients were monitored according to policy and that ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms, including call light cords, clothing, shoelaces, and personal belongings. This failure was identified in four of the twelve patients reviewed who presented with psychiatric complaints.

Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure suicidal patients were monitored according to policy and that ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms, including call light cords, clothing, shoelaces, and personal belongings. This failure was identified in four of the twelve patients reviewed who presented with psychiatric complaints. (Patients #4, #25, #22, and #27)

Findings include:

Facility policies:

According to the Suicide Precautions policy, suicide precautions shall be initiated on all patients with the potential for self-directed harmful behavior. The Ask Suicide-Screening Questions (ASQ) risk screen level will guide the precautions needed to keep the patient safe. In the case of an acute positive screen, staff shall initiate suicide precautions immediately to protect the patient as this patient is at the highest risk of suicide and self-harm. An acute positive screen requires staff to place the patient in a private room near the nurse's station, 1:1 monitoring, to place the patient in a paper gown without strings. The registered nurse (RN) will remove all patient personal belongings from the room and complete the suicide risk precaution checklist at the time a patient is placed under suicide precautions and with every bedside hand-off and shift report. Patients on suicide precautions shall not be allowed to go into the bathroom alone and close the door. Staff must remain with the patient and maintain line of sight supervision. A safe environment shall be maintained to protect the patient from injury.

According to the Patient Rights and Responsibilities policy, the staff should ensure all patients have their rights supported. Patients have a right to access to care including accommodations or treatment that are available and medically indicated.

According to the Policies of the Emergency Department policy, the reason is to stabilize and care for the acutely ill and injured patient, to provide care on a continuous basis, to provide quality care of the patient and family, to be aware of the patients' clinical and personal needs, meeting them with rapid response, to provide adequately trained personnel, current equipment, and a safe environment at all times, and
to respond to the needs of the patient.

1. The facility failed to remove ligature risks from patient care rooms and failed to monitor suicidal patients according to policy.

A. Observations

i. Observations conducted on 2/27/24 at 9:02 a.m. revealed the facility had an isolation room, room #9, which did not contain a call light, corded monitoring equipment, or any items affixed to the wall. However, standard patient rooms in the emergency department did contain call lights connected to the wall by a cord. Patient rooms also contained monitoring equipment with attached cords, as well as examination equipment affixed to the wall (otoscope). The two patient bathrooms in the emergency department contained a pull cord affixed to the wall for patients to use if they needed assistance.

B. Document Review

i. Medical record review revealed on 1/8/24 at 5:16 p.m., Patient #4 presented to the emergency department (ED) after overdosing on two grams of naproxen (a nonsteroidal anti-inflammatory medication used to treat pain). At 5:16 p.m., RN #15 administered an ASQ screening and classified Patient #4 as an acute positive screen for suicide. RN #15 initiated suicide precautions at 5:16 p.m., indicating the call light, and monitoring cords, would be removed from Patient #4's room, Patient #4 would have continuous 1:1 monitoring, and Patient #4 would not be permitted to use the restroom alone.

On 1/8/24 at 5:16 p.m., RN #15 documented the call light was within reach of Patient #4, and Patient #4 was placed on the cardiac monitor (a device with multiple cords attached to the patient used to monitor heart rhythm).

From 1/8/24 at 5:16 p.m. to 1/9/24 at 4:16 p.m., ED Nursing Notes revealed the call light was within Patient #4's reach 14 times. Additionally, ED Nursing Notes revealed that Patient #4 ambulated to the restroom three times during their ED admission, without 1:1 monitoring. There was no evidence that Patient #4 received 1:1 monitoring during their stay.

This was in contrast to the Suicide Precautions policy which required patients to have 1:1 monitoring when suicide precautions were implemented.

ii. Medical record review revealed on 2/8/24 at 1:12 p.m., Patient #22 presented to the ED after overdosing on Zoloft (a medication used to treat mood disorders and depression). RN #17 administered an ASQ screening at 3:24 p.m. and classified Patient #22 as an acute positive screen for suicide. RN #17 initiated suicide precautions at 3:24 p.m. At 4:23 p.m. ED nursing notes revealed Patient #22' s mother told staff at 4:23 p.m. that they had been 1:1 with Patient #22 since 10:00 a.m.

At 4:23 p.m., approximately three hours after the patient presented to the ED, the ED nursing notes revealed the patient's shoes were sent to security due to there being laces in the shoes. At 5:45 p.m., the ED nursing notes revealed the patient's personal clothing was collected and Patient #22 was placed in a paper gown. There was no evidence Patient #22 received 1:1 monitoring by a trained staff member during their stay.

This was in contrast to the Suicide Precautions policy which required patients who screened acute positive to have 1:1 monitoring, to have personal belongings removed, and to be placed in a paper gown.

iii. Medical record review revealed on 2/22/24 at 1:53 p.m., Patient # 27 presented to the ED for a mental health evaluation after making suicidal and homicidal statements. RN #11 administered an ASQ screening at 2:09 p.m. and classified Patient #27 as an acute positive screen for suicide.

ED nursing notes revealed Patient #27's grandmother was at Patient #27's bedside on 2/22/24 at 2:23 p.m., 2:35 p.m., 5:08 p.m., 7:09 p.m., 10:12 p.m., and on 2/23/24 at 12:51 a.m., 2:09 a.m., 3:52 a.m., 4:40 a.m., 7:18 a.m., 10:17 a.m., and 4:33 p.m.

From 2/22/24 at 1:53 p.m. until 2/23/24 at 6:04 p.m., there was no evidence that Patient #27 received 1:1 monitoring from a trained staff member during their stay.

iv. Medical record review on 2/26/24 at 11:30 a.m., Patient #25 presented to the ED for a mental health evaluation. RN #16 administered an ASQ screening at 11:30 a.m. and Patient #25 was classified as an acute positive screen for suicide. At 11:30 a.m., RN #16 documented the call light was within Patient #25's reach.

C. Interviews

i. An interview was conducted with RN #4 on 2/27/24 at 9:02 a.m. RN #4 stated patients placed in the isolation room (room #9) would be changed into paper scrubs, and their clothing would be cataloged. RN #4 stated room #9 was the only isolation room. RN #4 stated if multiple patients required 1:1 monitoring, a patient would be placed in a standard exam room. RN #4 stated staff would pull all things out of the standard exam room that a patient could use to hurt themselves. RN #4 stated someone would sit in the doorway of the standard room to conduct 1:1 monitoring.

An additional interview was conducted on 2/28/24 at 3:31 p.m. with RN #4. RN#4 stated suicide precautions occurred when a patient was placed in emergency room #9. RN #4 stated the patient would be placed in a gown or paper scrubs, and the patient's items would be cataloged and sent to security. RN #4 stated a patient on suicide precautions would have a sitter. RN #4 stated the facility had used family members as a sitter for patients on suicide precautions. RN #4 stated patients would be placed on suicide precautions if they made statements of self-harm. RN #4 stated it was important to place patients on suicide precautions to prevent completion of a suicide attempt. RN #4 stated the risk of not monitoring a suicidal patient included having access to call light cords or bathroom cords. RN #4 stated all cords would be removed if a suicidal patient was placed in a back room, and a sitter would remain in the doorway of the room. RN #4 stated the risk of not monitoring or not removing a cord would be strangulation.

ii. An interview was conducted on 2/28/24 at 4:26 p.m. with chief nursing officer (CNO) #7. CNO #7 stated the facility did not have a specific training process for mental health sitters in the emergency department. CNO #7 stated patients on suicidal precaution should not have had call lights within their rooms because this was a ligature risk.

An additional interview was conducted on 3/4/24 at 1:06 p.m. with CNO #7. CNO #7 stated it was not appropriate to use family members as sitters conducting 1:1 monitoring of patients placed on suicide precautions. CNO #7 further stated each room in the emergency department had different levels of risk to patients placed on suicide precautions.

iii. An interview was conducted on 2/28/24 at 1:15 p.m. with emergency physician (Physician) #2. Physician #2 stated triage nurses determined if a patient was suicidal. Physician #2 stated suicidal patients who were not placed in emergency room #9 were required to have a sitter. Physician #2 stated parents of adolescent patients counted as sitters, and they were unsure if a family member could be a sitter for an adult patient. Physician #2 stated cords were removable from all ED rooms. Physician #2 stated there was a risk of harm if a cord was left in a suicidal patient's room. Physician #2 stated suicidal patients were escorted to the restroom in the ED, and it was important to monitor suicidal patients in the restroom to prevent harming themselves.

iv. An interview was conducted on 2/28/24 at 3:00 p.m. with Physician #3. Physician #3 stated suicidal patients were placed with a sitter and the patients would be put in a gown. Physician #3 stated the room should have been cleared of personal effects including clothing or items that could have been hidden. Physician #3 stated call lights would be left in the patient's room unless the patient was in room #9, which did not have a call light. Physician #3 stated staff who monitored suicidal patients must have basic knowledge of working with psychiatric patients. Physician #3 stated it was important for sitters to be trained on how to react and de-escalate situations for patient and staff safety. Physician #3 stated 1:1 monitoring would be important because there were many distractions in the emergency department. Physician #3 also stated it would not be permissible for a family member to monitor suicidal patients for safety due to concerns for domestic violence. Physician #3 stated that patients could have used a call light or cords as ligatures to hang themselves. Physician #3 stated it would be important to have a 1:1 monitor for suicidal patients, and there would be an increased risk for harm if no monitoring were conducted.

v. An interview was conducted on 3/4/24 at 2:10 p.m. with quality and risk director (Director) #9. Director #9 stated even if family members were present with a suicidal patient, the facility still needed to have a staff member present to conduct 1:1 monitoring. Director #9 stated staff who provided 1:1 monitoring needed training, and it would not be appropriate for a family member to be a sitter even if the same training were provided to the family member.