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Based on the seriousness of the noncompliance, the facility failed to substantially comply with this condition. Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to comply with this condition.

These following standards were cited and show a systemic nature of noncompliance with regards to patient rights as follows:

482.13 (c)(2) Tag A-0144 The information and video recording reviewed during the survey provided evidence that personnel failed to ensure that an involuntarily committed, suicidal patient remained in a safe setting by allowing the patient to exit the facility, subsequently resulting in the patient's elopement by vehicle, for one of one medical record reviewed, by failing to complete the suicide risk assessment of emergency department patients for eleven of twenty-one medical records reviewed, by failing to obtain a physician order for observation of a patient who presented to the emergency department with suicidal ideations for one of one medical record reviewed, and by failing to follow security procedures to ensure that patients who are a danger to themselves and others have their personal belongings secured for three of three medical records reviewed.

482.13 (a)(2) Tag-A-0118 The information reviewed during the survey provided evidence that personnel failed to identify a patient concern as a grievance, by failing to provide written acknowledgment and response to the complainant following their investigation for one of one medical record reviewed.

Based on review of facility documentation and medical record (MR) and interview with staff (EMP), it was determined that the facility failed to follow their adopted policy by failing to identify a patient concern as a grievance, and by failing to provide written acknowledgment and response to the complainant following their investigation for one of one medical record reviewed (MR1).

Findings Include:


Indiana Regional Medical Center ... Policy #: P.C. ... Patient Rights and Responsibilities policy and procedure dated September 27, 2020. "Purpose: ... IRMC believes that patients have certain rights and responsibilities while under our care and services. ... Patient Rights ... For quality, support and advocacy, you have a right: To be informed about hospital resources such as ethics committees and patient representatives, for resolving disputes, grievance and conflicts; To access internal grievance process and appeal to an external agency. ... ."


Indiana Regional Medical Center Policy #: H.P. 4A Subject: Patient/Family Complaint/Grievance Process policy and procedure dated May 29, 2020. "Purpose: To establish a process to address, respond, resolve and track grievances and complaints. Policy: It is the policy of Indiana Regional Medical Center to implement practices consistent with regulatory standards to manage individual grievances and complaints related to the care services received. It is also organization policy to assure that grievances are responded to in a timely, reasonable, and consistent manner to the appropriate departments for investigation, problem resolution and follow-up. ... Definitions: Complaint: A 'Complaint' is an issue considered resolved by staff present when the patient is satisfied with actions taken on their behalf, or the nature of the complaint does not meet the definitions of a grievance. * 'Staff Present' is defined as any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisor, patient advocates, etc..) to resolve the patients complaint. All complaints regardless of the source (written, verbal, email, fax, website or telephone call) and regardless who the recipient is (CEO, VP, switchboard operator, nurse, etc.) of the complaint, shall be sent to the Patient Advocate/designee for formal processing. ... If the complaint or grievance is initiated by someone other than the patient or the patient's representative, for example, a friend, neighbor, or relative, the Medical Center will respond to the initiator with a letter acknowledging receipt of the complaint or grievance. The letter will note that the matter will be reviewed and that the initiator should encourage the patient to contact the Medical Center directly. ... Grievance: A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present) ... When the patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to another staff member for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance. * 'Staff Present' is defined as any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisor, patient advocates, etc.) to resolve the patient's complaint. ... ."

1. MR1, patient's demographic sheet revealed documented evidence of the patient's significant other, who was noted to have filed a complaint/grievance with the facility on July 26, 2023, as identified on the facility's complaint/grievance log. MR1 demographic sheet also revealed that the patient was admitted to the ED on July 24, 2023, at 3:08 PM and discharged on July 25, 2023, at 11:50 PM.

2. Facility documentation revealed that a "Complaint" was received on July 26, 2023, at 9:45 AM. The documentation also revealed that additional staff interview was conducted to complete the complaint investigation.


3. Interview with EMP9 on August 16, 2023, revealed that this was investigated as a complaint and not a grievance therefore, there is no documented evidence of an acknowledgment or final letter to the complainant.

Based on review of facility documentation, security camera footage and medical records (MR) and interview with faiclity staff (EMP), it was determined that the facility failed to provided care in a safe setting by failing to ensure that an involuntarily committed, suicidal patient remained in a safe setting by allowing the patient to exit the facility, subsequently resulting in the patient's elopement by vehicle, for one of one medical record (MR1), by failing to complete the suicide risk assessment of emergency department patients for eleven of twenty-one medical records (MR1, MR7, MR8, MR9, MR10, MR13, MR14, MR16, MR18, MR20 and MR21), by failing to obtain a physician order for observation of a patient who presented to the emergency department with suicidal ideations for one of one medical record (MR20), and by failing to follow security procedures to ensure that patients who are a danger to themselves and others have their personal belongings secured for three of three medical records(MR1, MR20 and MR21).


Findings Include:

Indiana Regional Medical Center ... Policy #: P.C. ... Patient Rights and Responsibilities policy and procedure dated September 27, 2020. "Purpose: ... IRMC believes that patients have certain rights and responsibilities while under our care and services. ... Patient Rights ... For our staff and environment, you have a right: To receive respectful care given buy competent personnel in a setting that: Is safe and promotes your dignity, positive self-image and comfort; ... Care in a safe setting, free from abuse and harassment. ... For quality, support and advocacy, you have a right: ... You have the right to respectful quality care and high professional standards that are provided by competent personnel. ... ."

Review of "IRMC Policy #: 66 Subject: Care of the Psychiatric and Behavioral Patients in the Emergency Department" March 28, 2022. "... Objective: To assure psychiatric and behavioral patients are managed in a safe and effective manner while ensuring their safety and the safety of IRMC patients and staff. Triage: 1. These patients will be triaged in the same manner as any other patient and prioritized as a 1 or 2 (active threat or actual harm) or 3 (verbal threat, stated intent of harm, or expression of any time psychiatric related aliment/complaint). 2. Patient exhibiting suicidal and/or homicidal ideation, attempted suicide and/or homicide or an intentional overdose will be placed directly in exam room 4, if available, or within staff/security's direct line of sight of the patient. 3. ED Charge Nurse will be notified. 4. ... SPECIAL NOTE: Any patient exhibiting suicidal and/or homicidal ideation, attempted suicide and/or homicide or an intentional overdose, shall be immediately placed under continuous 1:1 observation by a member of the Emergency Room staff, security, or other responsible party. Continuous observation may not be provided by a family member(s), police officer(s), etc. Continuous observation will be maintained unless discontinued by a written physician's order. ... 6. Patient clothing and all belongings are removed form the room and secured at the nurses' station for any patient exhibiting suicidal and /or homicidal ideation, attempted suicide and/or homicide, or an intentional overdose AND other patient thought to be at risk to self/others. RN who does the nursing psychiatric assessment is responsible for removing clothing/belongings from the patient and record this information in the medical record. 7. All secured belongings will be checked by security/designee, placed in the nurses' station, and findings will be recorded on the inventory sheet. ... Upon completion of psychiatric screening, the ED Physician is responsible to determine need for continued continuous 1:1 observation. ... 1:1 OBSERVATION: 1. ED nursing staff will provide 1:1 until such time that additional support from security or other responsible party arrives. ... ."

Review of "Indiana Regional Medical Center Policy#: P.C. 108 Subject: Nursing Documentation policy and procedure dated March 28, 2022. "... Policy: Thorough nursing documentation is an essential form of communication for the deliverance of effective patient care. Proper nursing documentation of all interventions along with reassessment of the patient's initial complaint, vital signs and other responses paints a picture of the patient's condition throughout their Emergency Department stay. Purpose: To document the accurate and ongoing nursing assessment of physical and psychosocial concerns of patients presenting for care in IRMC's Emergency Department. ... Procedure: 1. Assessment documentation will be completed as indicated by patient's chief complaint in the EMR. A. Triage Part One b. Triage Part Two c. ED Focused Assessment d. Systems Based Assessment [based on chief complaint] 2. Ongoing documentation of reassessment of patient will occur at least every 20 minutes for ESI Level 1 and 2 patients, and every 1 hour for Level 3, 4, and 5. Documentation should include: ... e. psychiatric reassessments and restraint documentation per policy ... ."

Review of "Indiana Regional Medical Center Policy#: P.C. 201 Subject: Suicide Risk Assessment: Columbia Suicide Severity Rating Scale" policy and procedure dated July 20, 2021. "... Purpose: To outline the process for the timely assessments and reassessments of patients' suicide risk and to provide guidelines for suicide precautions and prevention interventions. To assess an individual's current potential to engage in suicidal behavior using the Columbia Suicide Severity Rating Scale ... To use standardized language to promote universal communication. This will improve consistency, enable accurate assessment, and encourage an interdisciplinary treatment approach to suicide risk assessment and suicide prevention. ... Policy: It is the policy of Indiana Regional Medical Center to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors. Patients at risk for suicide require intensive support, close observation, frequent re-assessment, and application of protective measures for their emotional and physical well-being at all times. The scope of this plan begins prior to admission and continues through the patient's discharge. Patients age 13 and older will be assessed for their risk of self-harm using the Columbia Suicide Severity Rating Scale ... On every emergency department visit, at the time of admission to any inpatient department, at any time during inpatient hospitalization when a patient is perceived to be at increased risk for suicidal behaviors, prior to discharge of a patient from the inpatient setting. The C-SSRS assigns a level of risk to the patient. Patients identified, as a risk level [corresponding to a positive response to questions 3, 4, or 5] will have patient safety measures implemented as defined. When a patient triggers for a risk level of 3, 4, 5, a re-assessment of suicide risk must be completed every 12 hours using the C-SSRS. ... Suicide Risk Assessment: A comprehensive assessment of risk factors and protective factors of each patient to determine suicide risk [C-SSRS, Intensity of Ideation, Suicidal Behavior, and Actual Lethality and Medical Damage found online and in fast forms] ... Procedure: A. Initial Suicide Assessments The emergency department registered nurse/RN of department will complete the C-SSRS. ... 1. Initial suicide assessment will be completed on patients age 13 and older during triage in the ED and upon direct admission to the hospital. ... B. Further Suicide Assessment 1. To be completed in the emergency department by the registered nurse or psychiatric liaison, if available or registered nurse on the inpatient department for direct admits, or if the patient was unresponsive in the emergency room and admitted. a. C-SSRS b. Completion of the Intensity of Ideation c. Suicidal Behavior d. Actual Lethality of Medical Damages C. Re-Assessment of Suicide Risk 1. The RN will complete re-assessment of daily suicide risk screen every 12 hours for any patient who answers yes to questions 3, 4, or 5 on the C-SSRS. ... 4. Documentation a. Nursing will complete the C-SSRS b. MD will record all information ... D. Patient Monitoring: 1. Patients who are assessed to be at moderate [yes to question 3] or high risk [yes to questions 4, 5, or 6 on the C-SSRS may be placed on a one to one [1:1] or at the discretion of the attending physician based on presenting symptoms and behaviors at the time of the assessment or re-assessment. ... Patient Safety Monitors a. Nurse place order for a psychiatric consult with clinical rationale and notifies the physician. b. Patient placed on a one to observation [see below for 1:1 precaution]. c. All potential harmful items are removed [see below items] ... E. One to One Observation for Suicide 1. A one to one observation with time duration will be ordered by the admitting or attending physician. A physician order is necessary every day with clinical rationale. 2. A staff member will be assigned to be with the patient consistently and will complete the 15-minute checks by recording the information on the patient observation record. 3. Suicide precautions are to be communicated during every transition of care through hand-off communication. 4. A staff member is assigned to remain within arm's length of the patient at all times. 5. Staff assigned to observe patients on suicide precautions shall be vigilant to, immediately communicate to the registered nurse assigned to the patient, and document significant signs of concerns such as: a. suicidal statements or actions b. attempts to elude staff c. abrupt change in mood, either positive or negative d. self-isolation e. psychomotor agitation f. prolonged insomnia g. attempts to gain access to dangerous items such as sharps or housekeeping chemicals h. attempts to gain access to contraband items 6. Staff are to maintain a safe and therapeutic environment for all patients. Additional safety interventions are implemented for patients on suicide precautions. These interventions include, but may not be limited to: a. Safety and security will complete the search of patients in the ED b. Perform a thorough search of patient's clothes, personal articles and belongings to ensure that any items which might be used in a self-harmful way are confiscated and secured. Staff will document events in the medical record. i. Remove all potential ligatures [shoelaces, belts, cords/draw strings, etc.] ii. Additional, harmful items are removed from the room, i.e. sharp objects, razors, hangers, mirrors, glass, matches/lighters, cell phones, electrical appliances, etc. ... 8. The patient is not transported off the nursing units unless it is with a 1:1 observation. ... . "


Review of "Indiana Regional Medical Center Policy#: P.C. 75 Subject: Search and Confiscation policy and procedure dated March 28, 2022. "... Purpose: In order to ensure the safety of the Indiana Regional Medical Center employees and patients, patient searches shall be conducted on those individuals whom IRMC personnel have reason to believe possess an item or substance that could harm to themselves or others, or present to the Emergency Department in an unresponsive state. Policy: This includes, but is not limited to, all Section 302 commitment patients. This policy provides a procedure to be followed when searching a patient, as well as a procedure to be followed when the search reveals a harmful item. Procedure: A. Search 1. If IRMC personnel have reason to believe that an individual seeking treatment possess an item or substance that could cause harm to either himself/herself or others, both the individual and his belongings shall be searched. This is a private search; therefore, the patient cannot claim any constitutional violations. [only the government can violate the constitution]. 2. Prior to conducting the search, IRMC personnel shall attempt to obtain the patient's consent to the search if possible. If a weapon is suspected, or if it is felt the patient may become aggressive, the Safety/Security Department should attempt to obtain consent and do the search. If the individual is an emergency or mental health patient, his/her implied consent to treatment includes an implied consent to a reasonable search of the patient's person and personal belongings. ... B. Confiscation Patients will be assisted in removal of all clothes and placed in hospital gown. The Safety/Security Department personnel will complete the search except under extraordinary circumstances. If while searching a patient or a patient's belongings, IRMC personnel find any item or substance, excluding suspected or known illegal drugs, which they reasonable believe could cause harm to the patient or others, that item or substance shall be removed from the patient or the patient's belongings and given to Safety/Security Department personnel. ... ."




1. Review of MR1 revealed that the patient was admitted to the Emergency Department on July 24, 2023, at 3:08 PM with suicidal ideation, superficial cut to wrist with a plan to get into car and stab self. MR1 revealed documented evidence of a 302 commitment and was ordered 3:1 observation status. MR1 revealed that on July 25, 2023, the patient requested to see pet and security was notified, however, there was no staff member at that time that could accompany the patient outside as pets were not permitted in the facility. MR1 revealed that permission was sought and granted by the charge nurse and a staff member escorted the patient outside. MR1 revealed that the patient was with two staff members when the patient eloped into the vehicle and departed the ED parking lot.


2. Continued review of MR1 dated July 24, 2023, at 3:36 PM revealed consistent "yes" response to the "Columbia Suicide Severity Rating Scale [CSSRS]".


3. Further review of MR1 revealed that the patient had two personal cell phones, one was secured with belongings, the other was with the patient at the time of elopement.

4. MR1, Inventory of Personal Belongings sheet revealed a handwritten notation that no weapons were found and that two cell phones were secured and located in the pod locker, however, it was unclear as to when this occurred as the sheet was dated, "7-24-23-7-25-23."

5. Review of facility electronic mail documentation dated August 18, 2023, at 3:46 PM from EMP1 confirmed that MR1, Inventory of Personal Belongings sheet was used for both ED presentations, July 24, 2023, initial ED presentation, and July 25, 2023, ED presentation following the patient's elopement. EMP1 also confirmed that the patient's cell phones were not documented on the Inventory of Personal Belongings sheet as "Secured" or with applicable "Location" upon the patient's initial ED presentation, prior to the patient's elopement.


6. Review of security camera footage of the elopement event was conducted with EMP1 and survey team on August 15, 2023, at approximately 11:50 AM. At 1:03:15 PM the patient was seen exiting the Emergency Department with EMP3. The patient proceeded to the passenger side door of the vehicle parked at the end of the sidewalk, not in an assigned parking space. The patient opened the car door and sat in the passenger side of the vehicle. At 1:24:52 PM the passenger side vehicle door closed, at 1:25:31 PM the vehicle with the patient inside departed the parking lot.

7. Interview with EMP3 on August 15, 2023, at approximately 11:15 AM revealed that they were asked by the patient's nurse to take the patient outside and did so. EMP3 stated a car was parked outside the ED entrance with a driver and the patient's pet. EMP3 stated the patient was leaning over the front seat and the pet was in the back seat. EMP3 stated the patient's pet was making noise, the patient closed the car door and they drove off.
8. Interview with EMP7 on August 16, 2023 at 12:45 PM revealed by the time they went to the patient's room, the patient was already outside sitting in the passenger side of the car with the car door open. EMP7 continued that the patient's pet was in the car making noise, so the patient asked if the door could be closed, shortly thereafter, they drove off. EMP7 stated tat they later found out that the patient was in possession of own personal phone at the time of elopement.
9. Telephone interview with EMP8 on August 18, 2023, at 10:10 AM revealed that a patient could leave the building if they were calm and cooperative and that the patient came in with two cell phones, one was locked up and one was permitted to stay with self. EMP8 stated that they were unfamiliar with the contraband policy.

10. Review of facility documentation of the event revealed that the patient was admitted to Emergency Department (ED) on July 24, 2023, at approximately 3:00 PM, was escorted there by police, on a petitioned 302 commitment due to self harm (cuts on arms and suicidal and homicidal ideations and was deemed appropriate for 3:1 visual observation. The documentation revealed that on July 25, 2023, the patient requested to see pet and had used own personal cell phone to communicate with a person to execute this plan. The patient was permitted to exit the ED to visit pet, which moments later began to make noise uncontrollably such that the patient requested to close the door of the vehicle, subsequently departed the hospital premise.

11. Review of MR1, MR7, MR8, MR9, MR10, MR13, MR14, MR16, MR18, MR20 and MR 21 failed to reveal documented evidence of a complete suicide risk assessment with an assigned level or measurement of risk.
Telephone interview with EMP1 on August 18, 2023, at 10:00 AM, following a review of the records, confirmed the above findings.

12. Review of MR20 revealed documented evidence that the patient was suicidal. Continued review of MR20 revealed no documented evidence of a physician order for patient observation.
Further review of MR20 revealed there was there was no documented evidence of the Inventory of Personal Belongings sheet.
Telephone interview with EMP1 on August 18, 2023, at 10:00 AM, following a review of the record, confirmed the above findings.

13. Review of MR21 failed to reveal documented evidence where the "lighters," listed on the patient's Inventory of Personal Belongings sheet, were located and secured.
Telephone interview with EMP1 on August 18, 2023, at 10:00 AM, following a review of the record, confirmed the above findings.


14. Review of facility training slides revealed that all adult patients are assessed for risk of suicide upon admission using the Columbia-Suicide Severity Ratings Scale (CSSRS).

Continued review of facility training slides for staff responsibilities when sitting with a one to one revealed that patients at risk for suicide may be assigned one to one observation in which the staff must remain within arms length of the patient at all times, all harmful items must be removed from the patient and suicidal pateints are restricted use of cell phones.

15. Interview with EMP2 on August 15, 2023, at approximately 11:30 AM revealed that when it comes to cell phones, it's a "mixed bag" as patients may be permitted to have them.

16. Interview with EMP5 on August 16, 2023, at 12:00 PM revealed that it is left up to the nurse's discretion whether patients are permitted to have their cell phones.