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Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

The following observations of safety and ligature risks were observed on 04/13/2023 10:48 a.m. - 11:40 a.m. with S1DQ, S2DBH, and S3DF.

Room 'a': there was a gap between the bedside table and the wall enabling the bedside table to be used as a potential anchor point.
Room 'b': there was a gap between the headboard of the bed and the wall enabling the bed to be used as a potential anchor point.
Room 'c': there was a gap between the headboard of the bed and the wall enabling the bed to be used as a potential anchor point.

In an interview during the observation, S3DF verified the above stated findings.

The following observations of safety and ligature risks were observed on 04/13/2023 3:45 p.m. - 3:50 p.m. with S3DF.

Room 'd': there was a gap between the bedside table and the wall enabling the bedside table to be used as a potential anchor point.

In an interview during the observation, S3DF verified the above stated findings.

Based on record review and interview, the hospital action plan failed to identify after an adverse event that: 1) all hospital personnel in patient care areas maintained active CPR certification: and 2) failed to identify staff who were incorrectly initiating the Code Blue process according to policy which could impact the safety and quality of care of the patients.
Findings:

1. Review of the hospital's Policy and Procedure titled, "Cardiopulmonary Resuscitation" (CPR) revealed in part: 1. All hospital personnel witnessing respiratory and/or cardiac arrest has the responsibility of activating a code blue. 2. Licensed nursing personnel must have an American Heart Association BLS card or its equivalent and must remain certified at all times. 3. Nursing Assistant, Mental Health Techs, and Unit Secretaries who work with children under eight years old must have a "Heartsaver AED Adult and Pediatric" card. 6. The Education department is responsible for hospital-wide CPR training.

Review of the hospital's current employee list and training records from the "Ontrack Completion Report" dated 04/18/2023 failed to reveal S8Case Manager, S9Tech, S10Tech, S11RN and S12Tech were currently certified in their required CPR training.

In an interview following review of the report, S2DBH acknowledged the current employee list and the Ontrack report were correct.

2. Review of the hospital's Policy and Procedure titled, "Code Blue on Behavioral Health Unit" - Offsite Behavioral Health Campus revealed in part: Definition - "Code Blue" is the code used at the Offsite Behavioral Health Campus to summon immediate medical, nursing and support personnel to respond to any person experiencing a life threatening situation. All hospital personnel in patient care areas will maintain active CPR certification. Procedure: Steps 1. To initiate a Code Blue - A. Immediately access the overhead paging system to activate Code Blue. Key Points 1. Any staff member can call a "Code Blue" overhead, followed by the unit and room number or location of the patient. Immediately call 911 to request an ambulance to your address. 2. CPR is initiated according to emergency BLS guidelines and continued until Emergency Medical Services arrive and care is transferred.

In an interview on 04/18/2023 at 1:15 p.m. regarding the Code Blue process for their facility, S6LPN stated you call a "Code Blue" with the overhead paging system and then dial 111.

In an interview on 04/18/2023 at 1:20 p.m. regarding the Code Blue process for their facility, S4RN stated you call a "Code Blue" with the overhead paging system and then dial 111.

In an interview on 04/18/2023 at 1:25 p.m., S1DQ confirmed the offsite campus is to call 911 for Code Blue situations and the 111 is used for the Main Hospital's campus. S1DQ continued to state that initiation of Code Blue and CPR verification was not included in their action plan and post adverse event investigation and training.

Based on record review and interview, the hospital failed to ensure the training and experience of all personnel was adequate to meet the needs of the patient's as evidenced by: 1) failing to ensure all direct care staff maintained certification in CPR; and 2) failing to ensure staff were competent in responding to a "Code Blue" for 2 of 3 nursing staff interview as evidenced by using 111 instead of 911 (S4RN, S6LPN). This deficient practice had the potential to negatively impact the 7 patients on census in the children/adolescent unit at the time of survey.
Findings:

1. Review of the hospital's Policy and Procedure titled, "Cardiopulmonary Resuscitation" (CPR) revealed in part: 1. All hospital personnel witnessing respiratory and/or cardiac arrest has the responsibility of activating a code blue. 2. Licensed nursing personnel must have an American Heart Association BLS card or its equivalent and must remain certified at all times. 3. Nursing Assistant, Mental Health Techs, and Unit Secretaries who work with children under eight years old must have a "Heartsaver AED Adult and Pediatric" card. 6. The Education department is responsible for hospital-wide CPR training.

Review of the hospital's current employee list and training records from the "Ontrack Completion Report" dated 04/18/2023 failed to reveal S8Case Manager, S9Tech, S10Tech, S11RN and S12Tech were currently certified in their required CPR training.

In an interview following review of the report, S2DBH acknowledged the current employee list and the Ontrack report were correct.

2. Review of the hospital's Policy and Procedure titled, "Code Blue on Behavioral Health Unit" - Offsite Behavioral Health Campus revealed in part: Definition - "Code Blue" is the code used at the Offsite Behavioral Health Campus to summon immediate medical, nursing and support personnel to respond to any person experiencing a life threatening situation. All hospital personnel in patient care areas will maintain active CPR certification. Procedure: Steps 1. To initiate a Code Blue - A. Immediately access the overhead paging system to activate Code Blue. Key Points 1. Any staff member can call a "Code Blue" overhead, followed by the unit and room number or location of the patient. Immediately call 911 to request an ambulance to your address. 2. CPR is initiated according to emergency BLS guidelines and continued until Emergency Medical Services arrive and care is transferred.

In an interview on 04/18/2023 at 1:15 p.m. regarding the Code Blue process for their facility, S6LPN stated you call a "Code Blue" with the overhead paging system and then dial 111.

In an interview on 04/18/2023 at 1:20 p.m. regarding the Code Blue process for their facility, S4RN stated you call a "Code Blue" with the overhead paging system and then dial 111.

In an interview on 04/18/2023 at 1:25 p.m., S1DQ confirmed the offsite campus is to call 911 for Code Blue situations and the 111 is used for the Main Hospital's campus.