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Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidence by failing to ensure one (1) of thirty-three (33) sampled patients (Patient 1) was:

1. Provided care in a safe environmental setting in the emergency department (ED). Patient 1, who was identified as a 5051 hold (an involuntary hold/committing to mental care of a patient determined to dangerous in harming themselves or others) for suicide (the act of taking one's own life voluntarily and intentional) risk. (Cross refer A - 0114)

2. Provided Patient 1 continuous one-to-one monitoring (constant visual observation) according to facility's Suicide Risk Assessment and Interventions policy and procedure. (Cross refer A - 144)

The cumulative effect of these systemic problems resulted in the facility inability to ensure the Condition of Participation for Patient Right was met.

Based on observation, interview and record review, the facility failed to ensure one (1) of thirty-three (33) sampled patients (Patient 1) by failing to:

1. Provide care in a safe environmental setting, in the emergency department (ED). Patient 1, who was identified as on a 5051 hold (an involuntary hold/committing to mental care of a patient determined to dangerous in harming themselves or others), with suicide (the act of taking one's own life voluntarily and intentional) risk.

2. Provide Patient 1 continuous one-to-one monitoring (continuous observation of a patient) according to facility's Suicide Risk Assessment and Interventions policy and procedure.

This deficient practice resulted in Patient 1 being left unattended inside the ED Restroom 1. Patient 1 locked the ED Restroom 1 door, broke the glass mirror inside the ED Restroom 1, and used a broken piece of the glass mirror to stab herself 2 times on the neck (left and right side of the neck). Patient 1 was intubated and was transferred to intensive care unit (ICU) on 3/15/ 2023.

On 5/10/2023, at 2:20 PM, a complaint validation survey was conducted, and an Immediate Jeopardy (IJ) situation was called in the presence of the Chief Executive Officer (CEO), Chief Quality Officer (CQO), Chief Medical Officer (CMO), and Assistant Chief Nursing Officer (ACNO).

1. The facility failed to provide a safe environment for Patient 1, who was in the emergency department (ED) and was on 5051 hold (an involuntary hold/committing to mental care of a patient determined to dangerous in harming themselves or others).

2. The facility failed to ensure continuous one-to-one monitoring for a suicidal patient (Patient 1), who locked herself in the ED Restroom 1, broke the faucet, shattered the mirror, and cut herself in the left and right neck area with the mirror shards, while toileting in the ED Restroom 1.

On 5/11/2023, at 4:30 PM, during an onsite visit, the facility submitted an acceptable IJ Removal Plan. The IJ situation was removed in the presence of the CQO. The implementation of the IJ was verified. The IJ removal plan indicated the following:

1. The plan indicated to in-services the emergency department (ED) staff regarding facility's one-to-one monitoring of patients with suicide ideation (thoughts process of having ideas, or ruminations about the possibility of ending one's own life). The one-to-one monitoring included observation of the patient even while toileting in the restroom.

2. The plan included emergency department (ED) public restrooms, patient rooms, and/or any areas where patients with behavioral safety risks may be treated, will be checked as environmentally safe and free from harmful objects for patients with behavioral safety risks. The ED Restroom 1's gooseneck faucet (a faucet with a tall spout shaped in a rounded arc) was replaced with a more secured faucet. The ED Restroom 2's glass mirror was replaced with a shatter proof mirror.

3. The included staff assigned to monitor patients with behavioral safety risks will ensure that constant observation of the patient was provided, and staff will not leave the patient unattended, even while toileting.

Findings:

1. A review of local Fire Department Incident Information, dated 3/15/2023, indicated Patient 1 was transported to facility on 3/15/ 2023, at 12:10 AM, via ambulance for psychiatric crisis (a situation in which a person's action, feelings, and behavior can lead to hurting themselves or others) with Patient 1 making threats to herself while holding a pocketknife to her neck. Patient 1 was placed on 5150 hold by the local Sheriff Department.

A review of Patient 1's Nursing Assessment, dated 3/15/2023, at 4:04 AM, indicated patient denied suicidal ideation and denied having a suicide plan. Patient 1's Patient Safety Screener (PSS - 3, a screening tool used by facility suicide for patient at risk for suicide) was not done.

A review of Patient 1's Emergency Department (ED) Provider (physician) notes, dated 3/15/ 2023 at 8:46 AM, indicated Patient 1 had a sitter (Safety Attendant for continuous one-to-one monitoring), while waiting for psychiatric (involving mental illness) placement. Patient 1 had requested to go to the bathroom, and Patient 1 had locked herself inside the ED Restroom 1 by locking the door. The ED Bathroom 1 door had to be removed by engineering staff. Patient 1 was found inside the bathroom, standing and swaying, appeared pale, and was caught by staff to prevent Patient 1 from falling. The ED Bathroom 1 mirror was shattered and there was a large quantity of blood on the ED Bathroom 1 floor. Patient 1 was placed on a gurney and into an ED room for stabilization. Patient 1 was started with an intravenous (IV, into the vein) lines and was intubated (a tube through a patient's mouth down into windpipe to help with breathing). Patient 1 had, "Several punctures (stab wounds) to both side of her neck and has a slow bleed to the R (right) neck which appears venous (vein blood vessel), not pulsatile, likely EJ (external jugular, a long vein in the neck), controlled by direct pressure." The note indicated the other noted of stab wound for Patient 1 was on the left neck as a, "Small superficial hematoma (a pool of clotted blood formed under the skin) was seen over the left platysma muscle (superficial layer of muscle within the subcutaneous tissue [the layer of tissue underneath the skin] of the neck). The note indicated Patient 1 had a CT (a procedure by an X-ray machine to make detailed pictures in the body) of neck showed no injury to patient's large blood vessels in the neck carotid (large artery in the neck) and internal jugular (large vein in the neck). Patient 1's CT of brain showed no brain hemorrhage and neck laceration from a suicide attempt. Critical Care physician evaluated Patient 1 for transfer to Intensive Care Unit (ICU, provides care of patients who are acutely unwell and require critical medical care) and intubated Patient 1.

A review of Patient 1's Medical Record from 5/15/2023 at 9:43 AM to 5/15/23 at 1 p.m. (13:00), indicated nursing documentation regarding care provided to Patient 1 in the ED. Patient 1's medical record had no document information of Patient 1's self-inflicted injury (puncture or stab wounds) to the neck.

A review of Patient 1's Order Requisition, dated 3/15/23 at 12:49 PM, indicated Patient 1 was admitted to ICU.

On 5/8/2023 at 12:14 PM, during initial tour of the ED with Chief Quality Officer (CQO 2), Director of Quality (DQA 3), and Performance Improvement Analyst (PIA 2) stated ED has two public restrooms. Restroom 1 was observed inside the ER treatment area near Hallway 6 and across from Resuscitation room A & B. Restroom 1 was observed with an emergency pull cord by the toilet bowl, a gooseneck faucet (a faucet with a tall spout shaped in a rounded arc) on the sink. The gooseneck faucet was moveable and wobbly.

On 5/8/2023 at 12:14 PM, CQO 2 stated ED has two public restrooms. CQO 2 stated one (1) in ED lobby (Restroom 2) and another one in ED area treatment area (Restroom 1). CQO 2 stated both public restrooms in ED were not ligature (a string that can be used to something around the neck) free. CQO 2 stated patients identified with suicide risk and/or on a 5150 hold (the Welfare and Institutions Code that allows an adult who was experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [mental health) hospital] when a patient was evaluated to be a danger to others or to self). CQO 2 stated Restroom 2 was ED patients' use in the ED lobby. CQO 2 stated patients with 5150 holds, were brought into the ED were on one-to-one monitoring (continuously monitored) by a Care Partner (CP, certified nurse assistant [CNA] who functions as a patient Safety Attendant [facility staff assigned to do one-to-one monitoring and can be a CNA or a licensed nurse [Registered Nurse]). CQO 2 stated patient on one-to-one monitoring were allowed to use ED Restroom 1 with the CNA assigned to watch the patient.

On 5/9/2023, at 11:30 AM, during a concurrent interview with Informatics Staff (INF 2) and record review of Patient 1's local Fire Department Incident Information and Emergency Department (ED) Physician note, dated 3/15/2023, INF 2 stated Patient 1 arrived at the facility on 3/15/2023, at 2:25 AM, by fire department ambulance. INF 2 stated Patient 1 was brought to the ED as a 5150 hold by local law enforcement. INF 2 stated local law enforcement found Patient 1 holding a knife and Patient 1 had the knife aimed to the throat to harm self. INF 2 stated Patient 1 was seen by ED physician (MD 1), on 3/15/2023, at 2:38 AM and again by MD 2, on 3/15/2023, at 8:43 AM.

2. On 5/9/2023, at 11:30 AM, Lead Advance Service Provider for the ED (LASP - ED 1) stated Patient 1 was admitted to the facility on 3/15/2023, at 1:01 PM, and transferred to ICU for higher level of care.

On 5/9/2023, at 4:32 PM, during tour of ED with DQA 3 and PIA 2 and concurrent interview, ED Restroom 2 was observed with a glass mirror, diaper changing table, and emergency pull cord inside the restroom. DQA 3 stated this public restroom was for patients and all visitors in the ED waiting room.

On 5/9/2023, at 4:57 PM, during interview, Registered Nurse 2 (RN 2) stated Patient 1 was assigned under RN 2's care, on 3/15/2023. RN 2 stated he did not do a Patient Safety Screener (PSS - 3, a tool used to screen patients at risk for suicide), for Patient 1, on 3/15/23. RN 2 stated PSS - 3 was not done since Patient 1 was already identified as a suicidal patient by the transporting local Fire Department and was on a 5150 hold. RN 2 stated Patient 1 had a Care Partner (CP 2), who was assigned to do continuous one-to-one monitoring for Patient 1. RN 2 stated Patient 1 had a flat affect (a severely restricted or nonexistent expression of emotion). RN 2 stated Patient did not want to speak when asked with questions.

On 5/9/2023, at 4:57 PM, during interview, RN 2 stated on 3/15/ 2023 at approximately 9:25 AM, Charge Nurse 2 (CN 2) informed RN 2 that Patient 1 had locked herself in the ED Restroom 1. RN 2 stated CP 2 was outside the door. RN 2 stated he did not know why CP 2 was not in the restroom with the Patient 1. RN 2 stated security and engineering were called for assistance, to open the ED Restroom 1 door, because ED staff were unable to open the restroom door with the key. RN 2 stated the key used to open the ED Restroom 1 was the correct key. RN 2 stated the time spent trying to open the restroom door seemed like a long time. RN 2 stated, "I don't know how long it took." RN 2 stated after the ED Restroom 1 door was finally opened, Patient 1 was found upright and standing with blood on her neck and on Patient 1's gown. RN 2 stated Patient 1 was able to walk to the gurney. RN 2 stated ED physician (MD 2) was present and applied pressure to Patient 1's neck, which was bleeding and covered in blood. RN 2 stated not documenting the stab wounds on Patient 1 after the self-inflicted stab wounds. RN 2 stated Patient 1 was given sedation (put to sleep), intubated (tube inserted into the mouth to the trachea [throat] to help with breathing), stabilized, and transferred to the intensive care unit for further care. RN 2 stated ED Restroom 1 was observed with blood on the floor, the sink faucet was broken, and the mirror above the sink was shattered with glass chards on the floor. RN 2 stated when Patient 1 locked herself in the ED Restroom 1. RN 2 stated Patient 1 broke the faucet. Patient 1 used it (the faucet) to break the glass mirror. RN 2 stated Patient 1 used the ED Restroom 1 mirror glass chards to stab her neck. Patient 1's RN 2 stated when accompanying a suicidal patient to the restroom, who was on 5150 hold, the CP should be inside the restroom with the patient with the back towards the door, and the patient would be within line-of-site (watching the patient) as patient does toileting.

On 5/9/2023, at 5:47 PM, during an interview, CP 2 stated on 3/15/2023, she was assigned to provide one to one monitoring for Patient 1. CP 2 stated Patient 1 asked to go to the restroom two times. CP 2 stated, the first time she accompanied Patient 1 to the ED Restroom 1, CP 2 instructed Patient 1 not to lock the door. CP 2 did not enter the restroom to provide Patient 1 privacy. CP 2 stated Patient 1 complied with the instructions (not to lock the ED Restroom 1 door). CP 2 stated Patient 1 asked to go to the ED Restroom 1, a second time (time no given). CP 2 stated Patient 1 was accompanied to the ED Restroom 1. CP 2 stated did not enter the ED Restroom 1 with Patient 1. CP 2 stated Patient 1 was instructed not to lock the ED Restroom 1 door. CP 2 stated Patient 1 did not allow CP 2 to enter the restroom, and Patient 1 locked the ED Restroom 1 door. CP 2 stated she did not know how long Patient 1 was locked in the restroom and out of the line-of-sight. CP 2 stated Patient was asked to unlock the door, but Patient 1 did not comply with the instructions to unlock the ED Restroom 1 door. CP 2 stated she notified CN 2 that Patient 1 locked herself in the ED Restroom 1 and security was called for assistance. CP 2 stated she heard a lot of banging noises while Patient 1 locked inside ED Restroom 1. CP 2 stated after staff opened the door, Patient 1 was found covered in blood on her green gown.

On 5/10/2023, at 9:32 AM, during concurrent observation of the facility's ED Restroom 1 and interview with Plant Maintenance Manager (Plant Mgr.) and Director of Plant Operations (Dir. Plant Ops.), Plant Mgr. observed moving the gooseneck faucet side-to-side and stated the faucet moves like side-to-side, normally. The Plant Mgr. stated the gooseneck faucet was the standard faucet used throughout the facility. The Plant Mgr. stated, on 5/15/2023, "Patient 1 pulled the gooseneck faucet and broke it off the sink." The Plant Mgr. stated Patient 1 broke the mirror, above the sink. The Plant Mgr. stated ED Restroom 1 faucet was replaced with same type of gooseneck faucet. The Plant Mgr. stated the shards of broken glass mirror were removed. The Plant Mgr. stated the ED Restroom 1 mirror was not replaced due to the incident with Patient 1, who injured self with the ED Restroom 1), on 3/15/2023.

A review of facility's Patient Safety Screener (PSS - 3) form, dated September 2020, indicated the following questions were to be asked for patients at-risk for suicide:
1. In the past two weeks, have you felt down, depressed, or hopeless?
2. In the past two weeks, have you had thoughts of killing yourself?
3. In your lifetime, have you ever attempted to kill yourself?
A "yes" response to questions #2 and #3 (if within 24 hours) indicated a positive screen (Patient at risk for suicide).

A review of Patient Rights and Responsibilities policy, dated 5/22/2021, indicated Patient rights included the right to receive care in a safe setting.

A review of facility's Suicide Risk Assessment and Interventions policy and procedure, dated 7/26/2022, indicated the following:
1. Patients will be evaluated to identify their risk for suicide on admission and as needed throughout the hospital stay.
2. Patients deemed at risk will be placed on appropriate precautions and evaluated further by a physician or licensed designee.
3. To foster a safe environment, all staff, including Safety Attendant, may scan the environment, remove, and report potentially unsafe conditions or items within the surroundings of a patient deemed at risk for suicide.
4. All patients ages 12 years and older who were in the ED triage, ED and inpatients units who present with possible suicide will be screened by a RN to detect their risk for suicide via the PSS - 3. The screening will occur during the ED triage, initial assessment, or inpatient admission process. The RN may re-screen for suicide risk via the PSS - 3, at any point during the patient's stay.
5. Presentations indicating possible suicide risk included suicide ideation or attempt, overdose, depression.
6. In the ED, if a patient was identified with potential suicide risk per PSS-3 screening tool, the RN will notify the ED provider immediately, for concerns of active suicide ideation and a Safety Attendant will be assigned to the patient to escort them to a designated area within the ED and will remain in constant visual observation of the patient until the ED provider assessment is completed.
7. If patient was screened positive by the RN and assessed by the provider as at risk for suicide, a Safety Attendant will be assigned to the patient and will remain in constant visual observation of the patient, RN will notify the attending provider, RN will place a social work consult to develop a patient safety plan.
8. The RN will supervise the Safety Attendant in the completion of environmental/personnel safety checklist.

Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met, as evidenced by:

1. Failure Complete a Patient Safety Screener (PSS - 3, a screening tool used by facility for patients at risk for suicide) according to facility policy and procedure for Suicide Risk Assessment and Interventions for one (1) of thirty-three (33) sampled patients. (Cross refer A - 0395)

2. Failure to assess and check whether the ED Restroom 1 was safe for Patient 1 to use according to policy and procedure for Suicide Risk Assessment and Interventions for one (1) of thirty-three (33) sampled patients. (Cross refer A - 0395)

3. Failure to develop a baseline care plan (goals, action steps, and appropriate timelines to address patient's medical, needs identified by the assessment and reassessments) addressing psychosocial ( management for patients at risk for suicidal concerns for one (1)of the thirty-three (33) sampled patients (Patient 8) in accordance with the facility's policy and procedure regarding care plans. (Cross refer A - 0396)

4. Failure to provide care for intravenous (IV, into the vein) therapy guidelines for one (1) of the thirty-three (33) sampled patients (Patient 8). Patients 8's peripheral IV tubing was not labeled (indicating patient name, date, type of solution, and initials of the preparer), and Patients 8's peripheral IV (in the vein) access site was not labeled (date, time, and initials of the person who started IV), as indicated by the facility's Intravenous Therapy policy and procedure manual. (Cross refer A - 398)

5. Failure to provide care regarding proper cleaning and disinfecting of the intravenous pump prior to use for one of thirty-three (33) sampled patients (Patient 4) to minimize the risk of transmitting organisms. (Cross refer A - 398)

6. Failure to provide intervention for pain management for three (3) of the thirty-three (33) sampled patients (Patient 10, Patient 14, and Patient 25) in accordance with the facility's policy and procedure for pain management. (Cross refer A - 398)

7. Failure to provide care by not disposing of used gloves and practicing proper hand hygiene after urine specimen collection in samples of one out of three emergency rooms' hallways (the hallway used by patients arriving by ambulance). (Cross refer A - 398)

The cumulative effect of these systemic problems resulted in the facility inability to ensure the Condition of Participation for Nursing Services was met.

Based on observation, interview and record review, the facility failed to ensure licensed nurses provide nursing care for one of (33) sampled patients (Patient 1). Patient 1 was in the emergency department (ED) and was on 5051 hold (an involuntary hold/committing to mental care of a patient determined to dangerous in harming themselves or others), on 3/15/20223, due to threats to harming self. The facility failed to:

1. Complete a Patient Safety Screener (PSS - 3, a screening tool used by facility for patients at risk for suicide according to facility policy and procedure for Suicide Risk Assessment and Interventions.

2. Assess and check whether the ED Restroom 1 was safe for Patient 1 to use according to policy and procedure for Suicide Risk Assessment and Interventions.

The deficient practice resulted to Patient 1 being able to harm herself and had to potential for other patient with suicide ideation (thoughts process of having ideas, or ruminations about the possibility of ending one's own life) not receiving a safe and proper care. (Cross refer A - 144).

Findings:

A review of local Fire Department Incident Information, dated 3/15/2023, indicated Patient 1 was transported to facility on 3/15/ 2023, at 12:10 AM, via ambulance for psychiatric crisis (a situation in which a person's action, feelings, and behavior can lead to hurting themselves or others) with Patient 1 making threats to herself while holding a pocketknife to her neck. Patient 1 was placed on 5150 hold by the local Sheriff Department.

1. A review of Patient 1's Nursing Assessment, dated 3/15/2023, at 4:04 AM, indicated patient denied suicidal ideation and denied having a suicide plan. Patient 1's Patient Safety Screener (PSS - 3, a screening tool used by facility suicide for patient at risk for suicide was not done.

On 5/9/2023, at 4:57 PM, during interview, Registered Nurse 2 (RN 2) stated Patient 1 was assigned under RN 2's care, on 3/15/2023. RN 2 stated he did not do a Patient Safety Screener (PSS - 3, a tool used to screen patients at risk for suicide), for Patient 1, on 3/15/23. RN 2 stated PSS - 3 was not done since Patient 1 was already identified as a suicidal patient by the transporting local Fire Department and was on a 5150 hold. RN 2 stated Patient 1 had a Care Partner (CP 2), who was assigned to do continuous one-to-one monitoring for Patient 1. RN 2 stated Patient 1 had a flat affect (a severely restricted or nonexistent expression of emotion). RN 2 stated Patient did not want to speak when asked with questions.

2. A review of Patient 1's Emergency Department (ED) Provider (physician) notes, dated 3/15/ 2023 at 8:46 AM, indicated Patient 1 had a sitter (Safety Attendant for continuous one-to-one monitoring), while waiting for psychiatric (involving mental illness) placement. Patient 1 had requested to go to the bathroom, and Patient 1 had locked herself inside the ED Restroom 1 by locking the door. The ED Bathroom 1 door had to be removed by engineering staff. Patient was found inside the bathroom, standing and swaying, appeared pale, and was caught by staff to prevent patient from falling. The ED Bathroom 1 mirror was shattered and there was a large quantity of blood on the ED Bathroom 1 floor. Patient 1 was placed on a gurney and into an ED room for stabilization. Patient 1 was started with an intravenous (IV, into the vein) lines and was intubated (a tube through a patient's mouth down into windpipe to help with breathing). Patient 1 had, "Several punctures (stab wounds) to both side of her neck and has a slow bleed to the R (right) neck which appears venous (vein blood vessel), not pulsatile, likely EJ (external jugular, a long vein in the neck), controlled by direct pressure." The note indicated the other noted of stab wound for Patient 1 was on the left neck as a "Small superficial hematoma (a pool of clotted blood formed under the skin) was seen over the left platysma muscle (superficial layer of muscle within the subcutaneous tissue [the layer of tissue underneath the skin] of the neck). The note indicated Patient 1 had a CT (a procedure by an X-ray machine to make detailed pictures in the body) of neck showed no injury to patient's large blood vessels in the neck carotid (large artery in the neck) and internal jugular (large vein in the neck). Patient 1's CT of brain showed no brain hemorrhage and neck laceration from a suicide attempt. Critical Care physician evaluated Patient 1 for transfer to Intensive Care Unit (ICU, provides care of patients who are acutely unwell and require critical medical care) and intubated Patient 1.

A review of Patient 1's Order Requisition, dated 3/15/23 at 12:49 PM, indicated Patient 1 was admitted to ICU.

On 5/9/2023, at 4:57 PM, during interview, RN 2 stated on 3/15/ 2023 at approximately 9:25 AM, Charge Nurse 2 (CN 2) informed RN 2 that Patient 1 had locked herself in the ED Restroom 1. RN 2 stated CP 2 was outside the door. RN 2 stated he did not know why CP 2 was not in the restroom with the Patient 1. RN 2 stated security and engineering were called for assistance, to open the ED Restroom 1 door, because ED staff were unable to open the restroom door with the key. RN 2 stated the key used to open the ED Restroom 1 was the correct key. RN 2 stated the time spent trying to open the restroom door seemed like a long time. RN 2 stated, "I don't know how long it took." RN 2 stated after the ED Restroom 1 door was finally opened, Patient 1 was found upright and standing with blood on her neck and on Patient 1's gown. RN 2 stated Patient 1 was able to walk to the gurney. RN 2 stated ED physician (MD 2) was present and applied pressure to Patient 1's neck, which was bleeding and covered in blood. RN 2 stated Patient 1 was given sedation (put to sleep), intubated (tube inserted into the mouth to the trachea [throat] to help with breathing), stabilized, and transferred to the intensive care unit (ICU, unit where patients require critical medical care) for further care. RN 2 stated ED Restroom 1 was observed with blood on the floor, the sink faucet was broken, and the mirror above the sink was shattered with glass chards on the floor. RN 2 stated when Patient 1 locked herself in the ED Restroom 1. RN 2 stated Patient 1 broke the faucet. Patient 1 used it (the faucet) to break the glass mirror. RN 2 stated Patient 1 used the ED Restroom 1 mirror glass chards to stab her neck. Patient 1's RN 2 stated when accompanying a suicidal patient to the restroom, who was on 5150 hold, the CP should be inside the restroom with the patient with the back towards the door, and the patient would be within line-of-site (watching the patient) as patient does toileting.

On 5/8/2023 at 12:14 PM, during initial tour of the ED with Chief Quality Officer (CQO 2), Director of Quality (DQA 3), and Performance Improvement Analyst (PIA 2) stated ED has two public restrooms. Restroom 1 was observed inside the ER treatment area near Hallway 6 and across from Resuscitation room A & B. Restroom 1 was observed with an emergency pull cord by the toilet bowl, a gooseneck faucet (a faucet with a tall spout shaped in a rounded arc) on the sink. The gooseneck faucet was moveable and wobbly.

On 5/8/2023 at 12:14 PM, CQO 2 stated ED has two public restrooms. CQO 2 stated both public restrooms in ED were not ligature (a string that can be used to something around the neck) free. CQO 2 stated patients identified with suicide risk and/or on a 5150 hold (the Welfare and Institutions Code that allows an adult who was experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [mental health) hospital] when a patient was evaluated to be a danger to others or to self). CQO 2 stated patients with 5150 holds, were brought into the ED were on one-to-one monitoring (continuously monitored) by a Care Partner (CP, certified nurse assistant [CNA] who functions as a patient Safety Attendant [facility staff assigned to do one-to-one monitoring and can be a CNA or a licensed nurse [Registered Nurse]). CQO 2 stated patient on one-to-one monitoring were allowed to use ED Restroom 1 with the CNA assigned to watch the patient.

On 5/9/2023, at 5:47 PM, during an interview, CP 2 stated on 3/15/2023, she was assigned to provide one to one monitoring for Patient 1. CP 2 stated Patient 1 asked to go to the restroom two times. CP 2 stated, the first time she accompanied Patient 1 to the ED Restroom 1, CP 2 instructed Patient 1 not to lock the door. CP 2 did not enter the restroom to provide Patient 1 privacy. CP 2 stated Patient 1 complied with the instructions (not to lock the ED Restroom 1 door). CP 2 stated Patient 1 asked to go to the ED Restroom 1, a second time (time no given). CP 2 stated Patient 1 was accompanied to the ED Restroom 1. CP 2 stated did not enter the ED Restroom 1 with Patient 1. CP 2 stated Patient 1 was instructed not to lock the ED Restroom 1 door. CP 2 stated Patient 1 did not allow CP 2 to enter the restroom, and Patient 1 locked the ED Restroom 1 door. CP 2 stated she did not know how long Patient 1 was locked in the restroom and out of the line-of-sight. CP 2 stated Patient was asked to unlock the door, but Patient 1 did not comply with the instructions to unlock the ED Restroom 1 door. CP 2 stated she notified CN 2 that Patient 1 locked herself in the ED Restroom 1 and security was called for assistance. CP 2 stated she heard a lot of banging noises while Patient 1 locked inside ED Restroom 1. CP 2 stated after staff opened the door, Patient 1 was found covered in blood on her green gown.

On 5/10/2023, at 9:32 AM, during concurrent observation of the facility's ED Restroom 1 and interview with Plant Maintenance Manager (Plant Mgr.) and Director of Plant Operations (Dir. Plant Ops.), Plant Mgr. observed moving the gooseneck faucet side-to-side and stated the faucet moves like side-to-side, normally. The Plant Mgr. stated the gooseneck faucet was the standard faucet used throughout the facility. The Plant Mgr. stated, on 5/15/2023, "Patient 1 pulled the gooseneck faucet and broke it off the sink." The Plant Mgr. stated Patient 1 broke the mirror, above the sink. The Plant Mgr. stated ED Restroom 1 faucet was replaced with same type of gooseneck faucet. The Plant Mgr. stated the shards of broken glass mirror were removed. The Plant Mgr. stated the ED Restroom 1 mirror was not replaced due to the incident with Patient 1, who injured self with the ED Restroom 1), on 3/15/2023.

A review of facility's Patient Safety Screener (PSS - 3) form, dated September 2020, indicated the following questions were to be asked for patients at-risk for suicide:
1. In the past two weeks, have you felt down, depressed or hopeless?
2. In the past two weeks, have you had thoughts of killing yourself?
3. In your lifetime, have you ever attempted to kill yourself?
A "yes" response to questions #2 and #3 (if within 24 hours) indicated a positive screen (Patient at risk for suicide).

A review of facility's Suicide Risk Assessment and Interventions policy, dated 7/26/2022, indicated the following:
1. Patients will be evaluated to identify their risk for suicide on admission and as needed throughout the hospital stay.
2. Patients deemed at risk will be placed on appropriate precautions and evaluated further by a physician or licensed designee.
3. To foster a safe environment, all staff, including Safety Attendant, may scan the environment, remove, and report potentially unsafe conditions or items within the surroundings of a patient deemed at risk for suicide.
4. All patients ages 12 years and older who were in the ED triage, ED and inpatients units who present with possible suicide will be screened by a RN to detect their risk for suicide via the PSS 5. The screening will occur during the ED triage, initial assessment, or inpatient admission process. The RN may re-screen for suicide risk via the PSS - 3, at any point during the patient's stay.
6. In the ED, if a patient was identified with potential suicide risk per PSS-3 screening tool, the RN will notify the ED provider immediately, for concerns of active suicide ideation and a Safety Attendant will be assigned to the patient to escort them to a designated area within the ED and will remain in constant visual observation of the patient until the ED provider assessment is completed.
7. If patient was screened positive by the RN and assessed by the provider as at risk for suicide, a Safety Attendant will be assigned to the patient and will remain in constant visual observation of the patient, RN will notify the attending provider, RN will place a social work consult to develop a patient safety plan.
8. The RN will supervise the Safety Attendant in the completion of environmental/personnel safety checklist.

Based on observation, interview, and record review, the facility nursing staff failed to develop a baseline care plan (goals, action steps, and appropriate timelines to address patient's medical, needs identified by the assessment and reassessments) addressing psychosocial ( management for patient at risk for suicidal concerns for one (1) of the thirty-three (33) sampled patients (Patient 8) in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to delay necessary care and services due to the absence of an individualized care plan that contains information needed to properly care for Patient 8 and other patients.

Findings:

A review of Patient 8's ED Rapid Triage record, dated 5/1/2023 at 12:59 p.m., indicated Patient 8 was admitted due to complains of nausea, vomiting, and abdominal (stomach) pain.

A review of Patient 8's "History and Physical" (H&P), dated 5/10/2023, indicated Patient 8's medical history included diabetes (a disease in which the body's ability to regulate the amount of glucose in the blood is impaired), depression (a state of low spirits caused by loss of hope or courage), anxiety (a feeling of worry, nervousness, or unease), and gastroparesis (a condition that affects the muscles movement in the stomach).

During a concurrent interview with the Lead Advance Service Provider for Emergency Department (LASP - ED 1) and Informatic Specialist (INF 2) and record review of Patient 8's Care Plan, on 5/10/23 at 11:50 a.m., Patient 8's Care Plan, dated 5/7/2023, was reviewed. INF 2 verified that there was no care plan initiated to address Patient 8's psychosocial needs until 5/7/23 (six days after admission date, 5/1/2023).

During a concurrent observation and interview with, Patient 8, on 5/8/23, at 3:08 p.m., Patient 8 observed inside the Patient 8's room. Patient 8 observed and was calm. Patient 8 spoke in a low and slow tone. Patient 8 stated, "There are times that I feel anxious during my stay here, but I am glad to be going home."

During an interview on 5/8/23, at 8:05 p.m., Registered Nurse (RN 4) stated, "She (Patient 8) was found to have a BS (blood sugar) of 300 (normal levels 70 to 130 milligram, [mg, unit of measurement]/deciliter [dL, unit of measurement]), before meals, and less than 180 mg/dL after meals) on admission. RN 4 stated Patient 8 was admitted to the ICU (intensive care unit, provides care of patients who were acutely unwell and require critical medical care) and then transferred to the medical surgical unit (a medical unit provides care for a wide variety of conditions, such diabetes). RN 4 stated Patient 8 had panic attacks, and Patient 8 requested to speak to a psychiatrist. RN 4 stated Patient 8's doctor had placed Patient 8 on a one-on-one monitor (constant visual observation). RN 4 stated Patient 8 made some comments (no specified) to the doctor that warranted concern.

A review of the facility's policy and procedure (P&P) titled, "Suicidal (the act of taking one's own life voluntarily and intentional) Risk Assessment & Intervention," dated 2020, indicated, "The nurse will document the care plan and actions used to mitigate the risk for suicide." The purpose of the P&P was to assess and provide guidance to identify those patients at risk for suicide with the goal of delineating procedures and preventing self-inflicted injuries while in the hospital.

A review of the facility's policy and procedure (P&P) titled, "Provision of Patient Care," dated 2022, indicated, "Standards of nursing practices is to formulate a care plan or treatment regimen in collaboration with other disciplines and the patient to assure safety, comfort, hygiene, protection, prevention, and restoration of health."

Based on observation, interview, and record review, the facility failed to provide nursing services according to the facility's policy and procedure by:

1. Failing to provide care for intravenous (IV, into the vein) therapy guidelines for one (1) of the thirty-three (33) sampled patients (Patient 8). Patients 8's peripheral IV tubing was not labeled (indicating patient name, date, type of solution, and initials of the prepare), and Patients 8's peripheral IV (in the vein) access site was not labeled (date, time, and initials of the person who started IV), as indicated by the facility's Intravenous Therapy policy and procedure manual.

This deficient practice had the potential to leave patients with IVs not receiving proper care and at risk for intravascular (within the blood vessel) catheter (flexible tube) related infections.

2. Failing to provide care regarding proper cleaning and disinfecting of the intravenous pump prior to use for one of thirty-three (33) sampled patients (Patient 4) to minimize the risk of transmitting organisms.

This deficient practice had the potential to put patients with IVs and requiring use of an IV pump not receiving proper care, and patients at risk for infection as the IV pump may harbor harmful bacteria or viruses that can spread to the patient during the next use.

3. Failing to provide intervention for pain management for three (3) of the thirty-three (33) sampled patients (Patient 10, Patient 14, and Patient 25) in accordance with the facility's policy and procedure for pain management.

This deficient practice had the potential for patient to subject patients to unrelieved pain and prevent them from receiving effective pain management.

4. Failure to provide care by not disposing of used gloves and practicing proper hand hygiene after urine specimen collection in samples of one out of three emergency rooms' hallways (the hallway used by patients arriving by ambulance).

This deficient practice had the potential to expose patients to harmful bacteria or viruses that can spread from staff to patient and patients at risk for infections.

Findings:

1. A review of Patient 8's History and Physical (H&P), dated 5/1/23, indicated, Patient 8's medical history included diagnoses of diabetes (a disease in which the body's ability to regulate the amount of glucose in the blood is impaired), depression (a state of low spirits caused by loss of hope or courage), anxiety (a feeling of worry, nervousness, or unease), and gastroparesis (a condition that affects the muscles movement in the stomach). Patient 8's H&P lists indicated under, "Problem List" that the patient is at risk for infection. Patient 8 presented to the emergency department with recurrent severe abdominal pain, more than ten episodes of nonblood vomiting, and six episodes of nonblood diarrhea. The H&P indicated that one of Patient 8's chief complaints was that her anxiety and depression had worsened as a result of her stomach pain.

During a concurrent observation and interview with Registered Nurse 4 (RN 4), on 5/8/23, at 3:05 p.m., Patient 8's IV (intravenous-into-the-vein) tubing set was found to contain no label with date, time, or initials of the nurse. Patient 8's peripheral (pertaining to extremities such the hands or arms) IV catheter site to the left upper arm had no labeling with the time, date, and initials of the person who inserted the IV catheter. RN 4 stated Patient 8 had no IV administration set labeling and also verified that there was no date, time, or initials label on Patient 8's peripheral IV.

During an interview on 5/8/23, at 3:10 p.m., with Specialist of Medical Surgical Service and Line, Telemetry Medical (MSLT 3), MSLT 3 stated that it is definitely important to follow the facility's policy and procedure to date IV catheters and IV tubing to know when they should be changed, and infection control to prevent cross-contamination (the transfer of harmful bacteria from one substance or object to another) and bacterial growth.

During an interview on 5/8/23 at 3:15 p.m., RN 4 stated the hospital guidelines for IV medication administration required nursing staff to label medications and the IV tubing prior to its use to ensure it was the right patient, the right medication, and the right order. RN 4 stated the process to hang IV medications or fluids included labeling the tubing with date and time and the nurse's initials, so the tubing can only be used for up to 96 hours without the risk of infection and as per the hospital's policy. RN 4 stated she did not label the IV tubing before using it (IV tubing) because she forgot. RN 4 said the reason she (RN 4) needed to follow the process was to ensure the patient's safety. RN 4 stated once the IV catheter was inserted, it (IV catheter) should be labeled with the date, time, and initials of the inserter as soon as it (IV catheter) was inserted. RN 4 stated it (IV site) was important that the IV site had a label with the date, time, and initials of the inserter to know when it (the IV catheter) needed to be changed.

A review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy," dated 8/23/22, the P&P indicated, "All IV sites will have the date, time, and initials of the nurse inserting the catheter. IV sites will be changed and rotated every 96 hours or if signs of phlebitis or infection are present." The P&P indicates that the purpose of these guidelines was to establish a policy that facilitates the safe administration of intravenous (IV) solutions (fluids) and medications.

2. A review of Patient 4's "History and Physical" (H&P), dated 5/4/23, indicated that Patient 4 presented to the emergency department for left upper quadrant pain that radiated to the left groin area. Patient 4's medical history included diagnoses of mild cognitive impairment (having trouble remembering, concentrating, or making decisions that affect everyday life), osteoporosis (a condition in which the bones become brittle and fragile), and hypertension (abnormally high blood pressure).

During a concurrent observation and interview on 5/8/23, at 3:00 p.m., with Supervisor Registered Nurse 2 (RCN 2), in the nursing station hallway, RCN 2 was observed coming out of a room at the end of the hallway with gloves on, pushing an IV pole with an IV pump attached. RCN 2 stated, "I am wearing gloves in the hallway because I am about to wipe this pump down for use." RCN 2 stated, "The process for cleaning these IV poles and pumps after a patient was discharged was to turn it (the IV pump and pole) into the CDP (Central Processing Department) to get the pump cleaned, but it (getting the IV pump and pole cleaned) will take too long." RCN 2 stated she was using the wipes to clean the intravenous pump. Observe RCN 2 continue to wipe the IV pump with the wipes. RCN 2 then pulled the IV pole with the IV pump and proceeded to enter Patient 4's room.

During an interview on 5/11/23 at 5:10 p.m., the Infection Preventionist (IP) stated the IV pump must not be used by just wiping it down with bleach. IP stated contaminants like blood cannot be removed by whipping with bleach. IP stated, "The IV pump must be sent out to go through a proper cleaning process." IP stated the proper cleaning procedure was, "The cleaning professional (CDP) will disassemble the pump, clean, package, and label it (the IV pump and IV pole) as ready to use before shipping it (the IV pump and IV pole) back on the unit to use for another patient."

A review of the facility's policy and procedure (P&P) titled, "Cleaning and Disinfection of Non-Critical Patient Care Equipment," dated 2022, the P&P indicated, "CDP performs disinfection after discharge." Equipment used on patients and sent to CDP for cleaning must be wiped down with hospital-approved disinfecting wipes and then immediately placed in the dirty utility room for pickup by CDP for processing."

3. a.) A review of Patient 10's ED Rapid Triage record, dated 5/8/2023 at 11:20 a.m., indicated Patient 10 was admitted to the emergency department (ED) for a head injury. The record indicate Patient 10 had headache 2 out of 10 (on a numeric pain scale with zero [0] as no pain and ten (10) as having severe pain). The note indicate, Patient 10's pain was due to, "After a fall while standing up coughing, he does not remember the event."

During a concurrent interview with the Informatic Specialist 2 (INF 2) and record review of Patient 10's Physician Progress Note, on 5/11/23 at 8:30 a.m., Patient 10's Physician Progress Notes, dated 5/8/23 was reviewed by INF 2. INF 2 stated there was a plan for Patient 10 to be transferred to a higher level of care for possible stroke intervention. INF 2 stated the physician recommended CTA (computer tomography, a diagnostic imaging test that produces detailed images of blood vessels).

During a concurrent interview with Lead Advance Service Provider for Emergency Department (LASP - ED 1) and record review of Patient 10's Emergency Department Rapid Triage, on 5/11/23 at 8:35 a.m., LASP - ED 1 reviewed Patient 10's Emergency Department Rapid Triage, dated 5/8/2023. LASP - ED 1 stated Patient 10 had no intervention or notification to the physician of the Patient 10's headaches. LASP - ED 1 stated there was no communication in the hand-off report (communicating concise clinical information about a patient's health condition) to the receiving facility of Patient 10's headache. LASP - ED 1 stated, "The headaches should have been communicated as it (headache) was one of the important symptoms that should be reported as this was one of the major symptoms to monitor in patients suspected of or at risk for stroke."

3. b.) A review of Patient 14's Patient Information record, indicated patient was presented to the facility's ED, on 3/2/23 at 4:18 p.m., and was discharge from the ED, on 3/2/23 at 11:09 p.m.

During a review of Patient 14's H&P, dated 5/2/23, indicated Patient 14 presented to the ED for complaints of experiencing vaginal pain for four months. Patient was unable schedule an appointment with her provider. The H&P indicated, "Patient 14 rates her vaginal pain as an 8/10 (Numerical Rating Scale; 0 is no pain and 10 is worst imaginable pain) in severity, non-radiating, and without no modifying factors."

During a concurrent interview with INF 2 and LASP - ED 1 and record review of Patient 14's nursing assessment Flow Sheet, on 5/11/23 at 8:00 a.m., INF 2 and LASP - ED 1 reviewed Patient 14's nursing assessment, Flow Sheet, dated 3/2/2023. The Flow Sheet indicated on 3/2/23 at 4:22 p.m., Patient 14 reported pain 8 out of 10 using the NRS ED pain assessment tool. LASP - ED 1 and INF 2 (both) stated and verified Patient 8's Flow Sheet had no documented intervention for Patient 14's pain during hospital stay from 3/2/23 at 4:18 p.m. to 3/2/23 at 11:09 p.m. (6 hours and 51 minutes). ED. LASP-ED1 stated, "It is important that Patient 14's rating of pain of 8/10 should be addressed."

3. c.) A review of Patient 25's H&P, dated 5/11/23, indicated that Patient 25 presented to the ED for left lower leg cellulitis (a bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). The H&P indicated that one of the listed plans of care was pain control.

During a concurrent interview with INF 2 and record review of Patient 25's nursing assessment Flow Sheet, on 5/11/23 at 1:40 p.m., Patient 25's nursing assessment Flow Sheet, dated 5/11/2023 was reviewed by INF 2. INF 2 stated Patient 25's nursing assessment Flow Sheet indicated, on 5/10/23 at 11:53 p.m., Patient 25 reported pain 5 out of 10 using the NRS ED pain assessment tool. INF 2 stated Patient 25's nursing assessment Flow Sheet indicated no intervention was provided for Patient 25's pain. INF 2 stated Patient 25's nursing assessment Flow Sheet had no reassessment documented until the following morning, on 5/11/2023. INF 2 stated the nursing assessment Flow Sheet had no documentation of nursing notifying the physician of Patient 25's pain.

During a concurrent interview with LASP - ED 1 and record review of Patient 25's Medication Administration Record (MAR), on 5/11/23 at 8:35 a.m., Patient 25's MAR was reviewed by LASP - ED. LASP - ED 1 stated Patient 25's MAR indicted a pain medication order, on 5/11/23 at 6:00 a.m. LASP - ED 1 confirmed pain medication orders were entered a day after Patient 25 reported having pain at 5/10. LASP-ED1 stated, "It is important that Patient 25's pain gets addressed."

A review of the facility's policy and procedure (P&P) titled, "Provision of Patient Care," dated 2022, indicated under general standard of care, "Patients can expect to have effective management of pain."

A review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 2020, the P&P indicated, "It is the responsibility of the primary physician team and of all healthcare providers to facilitate the pain-relieving process and expedite interventions, within their scope of practice, to keep patients comfortable by reporting complaints of pain to the nursing staff and/or physician before and within 15 minutes to 60 minutes after an intervention is performed."

4. During an observation in the ED's hallway (ambulance entrance hallway), on 5/9/23, at 9:55 a.m., RN 7 observed with gloves on, walking down the hallway carrying a specimen bag. RN 7 walked to the nurse's station and dropped off the specimen in a tray at the nursing station window's counter. RN 7 did not remove her gloves or sanitize her hands. RN 7 proceeded with the same gloves on and entered the physician's room. The ED Nurse Manager followed RN 7 into the physician's room and was observed speaking with RN 7.

During a concurrent observation of RN 7 in the presence of ED Nurse Manager and Associated Chief Nursing 1 (ACNO 1) and interview with RN 7, on 5/9/23, at 9:55 a.m., RN 7 observed turned around after being stopped by the ED Nurse Manager. RN 7 started to remove her gloves and held the gloves against the front of her scrub pant. RN 7 stated, "I forgot to remove the gloves. I should have taken the gloves off and washed my hands after dropping off the specimen at the nurse station." RN 7 stated the bag she was holding was a urine specimen. RN 7 stated she had just collected the urine specimen from a patient (Patient no identified). RN 7 stated the emergency department process was to drop off specimens, then remove the gloves and wash hands. Stated that it is important to remove gloves so as not to contaminate the surrounding environment.

During an interview, on 5/9/23 at 10:10 a.m. with ED Nurse Manager stated that she came right behind RN 7 to speak to RN 7 about wearing gloves after dropping off the specimen. ED Nurse Manager stated, "It is important to follow the facility's policy to remove gloves and sanitize hands immediately after collecting specimens."

During an interview on 5/9/23, at 10:10 a.m., ACNO 1 stated, "The facility's process is to doff gloves at the point of care (at the patient's room) and wash hands prior to dropping off the specimen." ACNO 1 stated It's (removing gloves and hand washing) important that everyone (including all staff) understand and comply with the infection control process."

A review of the facility's policy and procedure (P&P) titled, "Lippincott Procedures: Urine Specimen Collection, Random," dated 2022, indicated the last third step of urine specimen collection was to, "Remove and discard your gloves and, if worn, other personal protective equipment. Perform hand hygiene."

During a review of the facility's policy and procedure (P&P) titled "Hand Hygiene," dated 2021, the P&P indicated, the facility's staff " ...will follow the World Health Organization's (WHO) 5 Moments of Hand Hygiene indications for performance of hand hygiene." The WHO 5 Moments list five moments when hand hygiene is required. The third moment listed on the WHO 5 Moments indicated, "After a procedure or body fluid exposure risk."