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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 §482.13 PATIENT RIGHTS was out of compliance.

A-0144 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on document review and interviews, the facility failed to provide care in a safe setting through higher levels of patient safety monitoring and safety checks in two of two patients with multiple self-harm events. (Patients #4, and #5)

Based on document review and interviews, the facility failed to provide care in a safe setting through higher levels of patient safety monitoring and safety checks in two of two patients with multiple self-harm events. (Patients #4, and #5)

Findings include:

Facility policies:

The Suicide Risk Assessment and Management policy read, safety measures should align with methods of suicide attempts, i.e., pencil restrictions if a pencil was used for self-harm, or special observations for linens.

The Patient Observation Rounds policy read, patients placed on special precautions will be provided with increased levels of staff supervision to prevent risk of harm to self or others. This includes safety checks every 15 minutes, every five minutes, and 1:1 observations. It provides increased environmental safety by conducting regular environmental safety inspections and checks of the treatment unit.

1. The facility failed to provide care in a safe setting through higher levels of patient safety monitoring and timed routine safety checks.

A. Document Review

i. Patient #4 was admitted to the Compass unit (low acuity, adult unit) on 3/7/24 with bipolar disorder (a mental illness that causes extreme mood swings) with suicidal ideation (thinking about or planning suicide). A review of Patient #4's medical record revealed Patient #4 was placed on a 1:1 observation level on 3/9/24 for self-harming behaviors. The 1:1 observation level was removed on 3/11/24, and Patient #4 was placed on safety checks every five minutes. While on the five-minute safety checks, Patient #4 reached over the nurses' station desk and grabbed a pen for the purpose of self-harm. The medical record also revealed Patient #4 obtained a plastic hairbrush on 3/16/24 and broke it for the purpose of self-harm. Additionally, Patient #4 obtained seven plastic spoons and a second broken hair brush on 3/17/24 and intended to self-harm with the plastic edges of the brush and spoons. Patient #4 was not placed on a 1:1 level of observation during this time.

ii. Patient #4 was readmitted to the Compass unit on 4/13/24 with bipolar disorder with suicidal ideation. A review of Patient #4's medical record revealed Patient #4 was placed on five-minute safety checks on 4/14/24. On 4/14/24, staff discovered Patient #4 had a broken plastic spoon and a razor blade. Patient #4 remained on five-minute safety checks. Patient #4's medical record revealed on 4/15/24, Patient #4 banged their head against a wall and used a plastic spoon to cut themselves. An order for a 1:1 level of observation was obtained, however, documentation revealed the five-minute safety checks continued and Patient #4 was not placed with a 1:1 staff member for the higher level of observation.

Patient #4's medical record revealed on 4/16/24, Patient #4 attempted strangulation with a wall phone cord and banged their head against the wall to self-harm during the five-minute safety checks. Additionally, the medical record review revealed on 4/17/24, there was no evidence the five-minute safety checks were performed from 2:05 p.m. through 2:30 p.m. after Patient #4 attempted another wall phone cord strangulation at 11:00 a.m.

Patient #4's medical reveal no evidence the patient safety checks were performed on 4/22/24, 4/23/24, and 4/29/24. Patient #4 continued to have multiple episodes of self-harm events that involved plastic spoons, the coffee machine hot water dispenser, a shampoo bottle cap (attempted to swallow), and a tree stick from outside.

The medical record review revealed Patient #4's level of observation remained on five-minute safety checks despite additional self-harm attempts by Patient #4.

This was in contrast to the patient observation rounds policy which read, patients were provided with increased levels of staff supervision to prevent the risk of harm to self or others.

iii. A medical record review of Patient #5 revealed they were admitted on 2/29/24 to the Compass unit. On 3/5/24, staff learned Patient #5 had a small utility knife blade and the patient was placed on five-minute safety checks. Additional blades were found with Patient #5 on 3/6/24, 3/7/24, and 3/14/24. Patient #5 was increased to a 1:1 level of observation on 3/9/24 and was decreased back to five-minute safety checks on 3/11/24.

Patient #5's medical record review revealed on 3/13/24, the five-minute checks were missing three times on the day shift (8:15-8:30 a.m., 11:05-11:10 a.m., and 12:40-1:05 p.m.). On 3/14/24, another small utility knife blade was found in Patient #5's pocket. Patient #5 was placed on a 1:1 level of observation till 3/16/24 when they returned to the five-minute safety checks.

This was in contrast to the patient observation rounds policy which read, patients were provided with increased levels of staff supervision to prevent risk of harm to self or others. Furthermore, it was in contrast to the Suicide Risk Assessment and Management policy which read, safety measures aligned with methods of suicide attempts.

B. Interviews

i. On 6/20/24 at 12:28 p.m., an interview was conducted with behavioral health technician (BHT) #1. BHT #1 stated rounds were done every shift to check the environment for contraband (prohibited items patients used for harm to self or others). BHT #1 stated contraband included any items that could have been used as a weapon to harm the patient or others on the unit. Contraband included but was not limited to, razors, spoons, cords, linens, and phones. BHT #1 stated the patients had different levels of observation and the level was determined by the provider and the care team. BHT #1 stated when a patient was placed on a 1:1 observation level, there was a dedicated staff member with the patient within arm's length at all times.

BHT #1 stated patients who attempted self-harm with spoons were given finger foods to eat and not given access to the spoons. BHT #1 stated when patients went outside, they were watched for contraband but only checked the adolescent patients for contraband when they entered back into the facility. BHT #1 stated when patients who required 1:1 observation showered, they were watched on the opposite side of the shower curtain, but were still given shampoo bottles with lids on them. BHT #1 stated environment rounds and the correct level of observation were important so patients remained safe and could not hurt themselves or others. BHT #1 stated when patients did not have the correct level of observation, they were more likely to get injured or injure other patients or staff.

ii. On 6/20/24 at 10:01 a.m., an interview was conducted with nurse manager (Manager) #2. Manager #2 stated the difference between a five-minute safety check and a 1:1 was the 1:1 observation level was arm's length and the five-minute safety check had the patient in the staff member's line of sight. Manager #2 stated it was important to have the correct level of observation because it kept patients safe from harm. Manager #2 stated if patients went unmonitored, incidents of self-harm, suicide attempts, and completed suicides had an increased risk.

Manager #2 stated Patient #4 showered on 4/28/24 and had a shampoo bottle lid. Patient #4 was watched while in the shower and still attempted to swallow the lid. Manager #2 stated Patient #4 was on a 1:1 while outside on 4/29/24, but was able to get a tree stick when the staff member momentarily looked away. Manager #2 stated Patient #4 was able to get spoons from other patients during mealtime because Patient #4 was not on a 1:1 level of observation during those times. Manager #2 stated the treatment team decided the 1:1 level of observation was not therapeutic for Patient #4.

This was in contrast to the medical record review for Patient #4 which revealed Patient #4 was not on a 1:1 level of observation during their entire stay. Furthermore, Patient #4 had access to spoons and other objects used for self-harm and had the opportunity for self-harm when five-minute safety checks were not performed as revealed in the medical record review.

iii. On 6/20/24 at 10:45 a.m., an interview was conducted with the risk management director (Director) #3. Director #3 stated Patient #5 had several events where small utility blades were in their possession. Director #3 stated staff were unsure how Patient #5 hid multiple razors from staff. Director #3 stated Patient #5 was placed on a 1:1 level of observation until their investigation was completed.

This was in contrast to Patient #5's medical record which revealed Patient #5 had opportunities for self-harm when five-minute safety checks were not performed. Additionally, Patient #5's medical record revealed staff found the knife blades on Patient #5 before the 1:1 level of observation was implemented and after it was discontinued.