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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. The facility failed to have a process in place to ensure the safety of each patient who received care in the psychiatric units. Specifically, the facility failed to ensure a safe environment of care by not identifying and reducing ligature risks. The facility also failed to ensure interventions were implemented to prevent further suicide attempts and failed to ensure patients were monitored according to their plan of care for 6 of 13 patients admitted to inpatient psychiatric units (Patients #3, #6, #7, #9, #10, and #12) .

A-0175 The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. The facility failed to ensure patients placed in physical restraints and seclusion were monitored and assessed according to the facility's standards in 1 of 1 patient's medical record reviewed for restraint/seclusion (Patient #6)

Based on observations, interviews, and record review, the facility failed to provide care in a safe setting. Specifically, the facility failed to ensure a safe environment of care by not identifying and reducing ligature risks. The facility also failed to ensure interventions were implemented to prevent further suicide attempts and failed to ensure patients were monitored according to their plan of care for 6 of 13 patients admitted to inpatient psychiatric units (Patients #3, #6, #7, #9, #10, and #12) .

Findings include:

Facility policies:

According to the Precautions Policy, basic precautions are used for patients whose pre-admission assessment clearly indicated they are a danger to self or others. The type such as suicide, assault, arson, escape, etc should be clearly specified. Staff will know patient's location at all times and make personal observation of the patient at least every 15 minutes and document this by completing the Precaution Check Sheet. Staff will remove all potentially harmful personal effects from the patient and their room.

According to the Safety Checks for Patients Policy, all patients on adult, senior and child/adolescent psychiatric services units are on safety checks unless the need for a higher level of precaution has been identified and implemented. Safety checks are defined as a visual identification of the patient with his/her location and observable behavior at least every 15 minutes.

According to the Admission, Continued Stay and Exclusionary Criteria- Adult and Child/Adolescent Psychiatric Services Policy, general admission requirements include imminent risk to self as evidenced by suicidal threat or attempt with an inability to agree to be safe. The patient requires intense and continued observation, protection, treatment and or evaluation found only in an inpatient setting.

According to the Emergency Room Security Policy, Mental Health (MH) zone officer will perform a search on all MH patients' property received and patients who are transferred to another unit or facility to remove all items that would make an unsafe environment. If the patient is admitted to 2 North (adult and senior psychiatric units), security will provide an escort and the patient will be searched again when leaving the ED and upon arriving to 2 North. Potential suicide and/or dangerous patients shall be watched at all times. The officer may either be inside the room with the patient or view the patient in the monitor.

According to the Adult Psychiatric Unit General Information Policy, clothing with strings are not allowed (i.e. sweatpants with drawstrings).

According to the Intake Procedure Policy, upon entering the unit, the patient is informed of contraband items and informed of the policy on search and confiscation of such items. The accompanying staff member performs a search of the patients personal belongings, the patient may be required to empty all pockets, shoes, etc. All clothing, baggage and purses will be searched for contraband. Once the clothing is determined to be free of contraband, the patients will have their clothing returned.

1. The facility failed to monitor patients in a manner to prevent harm from identified ligature risks found throughout the psychiatric units; specifically, door handles.

a. On 8/27/18 at 3:00 p.m., a tour of the adult and senior psychiatric units was conducted. Inspection of both units revealed multiple ligature risk door handles outside of offices and non-patient rooms which were located in open hallways where patients were observed walking.

b. Review of Patient #3's medical record revealed the patient was admitted to the adult psychiatric unit and placed on suicide precautions for suicide ideation, severe depression and poor judgement.

On 6/25/18 at 7:50 p.m., Registered Nurse (RN) #2 documented an internal report which revealed Patient #3 was asked to stay in the side room for closer observation after the patient stated she wanted to kill herself and scratched her neck with a pencil. The report indicated a camera was located in the side room. Further documentation showed, at 9:10 p.m., Patient #3 was found hanging from the bathroom door handle by her shirt in the alcove (recessed area) area of the unit. Behavioral Health Specialist (BHS) #3 stated he observed Patient #3 two minutes prior to the incident on the camera. BHS #3 knocked on the bathroom door and when he got no response, he then retrieved a female staff to open the bathroom door and Patient #3 was found hanging from her shirt.

c. On 8/30/18 at 10:42 a.m., an interview with RN #4 was conducted. RN #4 stated patient rooms had been mitigated for suicide risks in which there were no locks on the bathroom doors and the bedroom handles were round, so items such as sheets would slide off to prevent a suicide attempt. RN #4 stated there was a suicide risk for patients in the unit hallways in which hallway doors, staff bathroom doors and the alcove bathroom door had elongated handles in which items could pose a hanging risk unlike the rounded bedroom door handles. RN #4 explained the side room was a room patients could go for quiet, however they would be observed every 15 minutes. Additionally, someone at the desk would monitor the side room with the camera. However, RN #4 stated no one was assigned to specifically monitor the camera at the desk; it would be whoever was sitting there.

d. Review of the Adult/Senior Behavioral Health-Environmental Risk Assessments dated 10/20/17 and 4/16/18, revealed the facility identified door handles as a ligature risk in "other doors, open hallways and offices". There was no evidence of a mitigation plan on the form for the identified door handles.

e. On 8/30/18 at 2:20 p.m., an interview with the Behavior Health Training and Compliance Coordinator (Coordinator #7) was conducted. Coordinator #7 explained he performed a ligature risk assessment of the psychiatric units most recently last spring. Coordinator #7 stated the door handles in the patient rooms were changed in 2017 to decrease the ligature risk. However, Coordinator #7 stated there were still areas on the adult and senior units which posed a risk to patients if left alone in the identified hallways and bathrooms with elongated door handles.

Coordinator #7 stated to mitigate the risk, they increased patient observation. Coordinator #7 stated the expectation was for staff to accompany patients when they used the bathroom in the alcove. There was no evidence staff accompanied Patient #3 to the bathroom on 6/25/18. Additionally, Coordinator #7 stated all risks could not be removed; therefore, staff were expected to increase rounding for patient safety.

f. On 8/30/18 at 11:44 a.m., an interview with Behavioral Health Director (Director) #8 was conducted. Director #8 explained she and Coordinator #7 had identified the door handles as a ligature risk but felt staff were vigilant with monitoring patients.

Director #8 stated she ordered new door handles for the alcove on 8/23/18, almost 2 months after Patient #3's suicide attempt. Additionally, Director #8 stated she did not feel it was important to change the door handles in common areas because staff were expected to monitor the patients. Director #8 stated there had been no process changes on the adult and senior psychiatric unit since Patient #3's suicide attempt.

2. The facility failed to ensure a streamlined process for monitoring patients presenting to the emergency department (ED) with suicide ideations which allowed Patient #12 to perform an act of self harm while unattended.

a. Review of Patient #12's medical record revealed she went to the emergency department (ED) with suicide ideations on 1/20/18 at 3:03 p.m. According to Registered Nurse (RN) #16's triage note at 3:06 p.m., Patient #12 stated her grandmother sent her to the ED for a psychiatric evaluation for making suicidal statements, but she had not performed any acts of self harm.

RN #15 performed a suicide screening of Patient #12 at 3:11 p.m. and scored her a low suicide risk even though she came to the ED with suicide ideations just eight minutes earlier. RN #15 documented safety precautions were in place as the patient was in view of the nursing station and hospital security at 3:21 p.m. According to ED Physician (Physician) #17's History of Present Illness (HPI), Patient #12 was allowed to use the bathroom prior to being seen by him. At approximately 3:40 p.m., Physician #17 was called to assist Patient #12 because she was not responding to staff from behind the locked bathroom door. Patient #12 was found in the bathroom, laying on the ground with her shirt tied tightly around her neck. Patient #12's face was purple and she had an abrasion on her neck and a possible loss of consciousness.

b. On 8/29/18 at 1:01 p.m., an interview with Behavioral Health Evaluator (Evaluator) #13 was conducted. Evaluator #13 stated her expectation was to be consulted for every patient admitted to the ED with a suicide attempt because it was a serious act. Evaluator #13 explained that a patient admitted to the ED with either suicide ideations or an attempt would be assigned to a behavioral health (BH) room so security could monitor them. Evaluator #13 explained there were only four rooms on the BH unit of the ED with a camera in each so security could monitor the patient. Additionally, if the BH unit was full, a security officer would be assigned to a patient with suicide ideations in a regular ED room. Evaluator #13 stated patients admitted with suicide ideations would have security assigned to them on admission to monitor them at all times.

c. On 8/29/18 at 1:44 p.m., an interview with RN #20 was conducted. RN #20 stated when a patient presented to the ED with suicidal ideations or suicide attempt security would meet the patient at triage to ensure patient safety until they were placed in a more secure area. RN #20 stated the psych protocol order set for a suicidal patient ordered them to be a 1:1 observation automatically. RN #20 explained the care was the same for a patient with suicidal ideations or suicide attempt because they would be considered a 1:1 as they were being observed by security. RN #20 stated any patient admitted to the ED with suicidal ideations would have a high suicide risk score since they were suicidal. Additionally, RN #20 stated any patient with a suicide risk would be observed while in the bathroom so they could be within arm's reach of a staff member for safety.

d. On 8/29/18 at 12:39 p.m., during a tour of the ED, Director #14 stated when a patient was admitted to the ED with suicidal ideations or suicide attempt, staff would escort the patient to the bathroom for safety. Additionally, Director #14 stated staff were able to make patients a 1:1 observation without a physician order to obtain a sitter or security guard. Director #14 stated a suicidal patient admitted to the ED would be scored a high suicide risk because they would require increased nursing observation.

On 8/30/18 at 7:30 a.m., an interview with Director #14 was conducted. Director #14 stated although Patient #12 went to the ED with suicidal ideations, she denied them at triage and therefore was not placed on suicide precautions. Director #14 stated Patient #12's suicide attempt was unsuccessful because of the processes that were in place. Director #14 stated there was not a clear policy which stated a patient was to be placed on a 1:1 when admitted for suicide ideation or suicide attempt; therefore it was staff discretion to make that decision. This was in contrast to her previous statement during the ED tour in which she stated patients admitted with suicidal ideation or suicide attempt would be escorted to the bathroom for safety.

Director #14 explained the staff might have treated Patient #12 differently since the staff knew her well because she visited the ED frequently and had a traumatic history. Director #14 stated patients were treated based on what staff knew about them such as their history, presentation and current complaints. Director #14 further stated if the RN felt the patient needed direct observation then security would be notified and they would monitor the cameras and keep patients in their line of sight. Director #14 stated patients that needed more observation would not go to the bathroom alone. Director #14 stated there had been no process changes regarding observation of suicide ideation patients in the ED since this incident nor any staff education. Additionally, Director #14 stated she would need to review facility policies to see if Patient #12 should have been monitored while in the bathroom.

3. The facility failed to implement actions after Patient #9 expressed an action of self harm in order to ensure the patient's safety and avoid a reoccurrence of a negative outcome. This resulted in a repeated act of self harm.

a. Review of the History of Present Illness located in Patient #9's medical record revealed the patient presented to the emergency department (ED) on 4/8/18 at 10:24 a.m. after trying to kill herself by ingesting seven Xanax (antianxiety) pills, blood pressure medications and alcohol. At 10:49 a.m., an order to notify security to implement 1:1 monitoring was placed; however, there was no documentation to show the 1:1 monitoring was being done.

At 3:14 p.m., nursing documentation revealed the patient attempted to drink betadine solution (a topical antiseptic used to kill bacteria, fungi and viruses) while in her ED room. Approximately 15 milliliters (ml) were missing from the bottle and the patient had betadine on her clothes. Physician ED course notes documented the patient was placed on an M1 (mental health) hold secondary to the patient reporting suicidal thoughts including shooting herself with a gun and intentional ingestion, as well as drinking betadine in the ED.

At 4:57 p.m., a psychological behavioral health evaluation was conducted by a licensed clinical social worker, who determined the patient was at a high risk for suicide as evidenced by her expressions of burdensomeness, expressions of not having a sense of belonging, and her acquired capacity to self harm. Further documentation from the evaluation revealed Patient #9 expressed a continuous desire to end her life and that she was hopeful the combination of alcohol and medications she took prior to her arrival to the ED would cause her heart to stop beating.

At 6:05 p.m., Patient #9 arrived to the inpatient psychiatric unit. According to a suicide risk assessment conducted at 6:08 p.m., the patient was determined to be at a moderate risk of suicide. There was no documentation in the assessment addressing the incident of Patient #9's attempt of self harm from ingesting betadine solution in the ED 3 hours earlier. Admitting orders to the psychiatric unit included placing the patient on suicide precautions. There was no further documentation noted as to whether the 1:1 monitoring order from the ED was expected to continue, how the patient would be monitored for safety, and which interventions would be placed to ensure the patient would be safe from additional self harm.

According to a psychiatric nursing note, at 7:15 p.m. the patient was found in her dorm with a puncture wound on her right wrist and a large puddle of blood on the floor. The patient was observed clenching her fist to make her wrist bleed more. It was found the patient took the soap dispenser in her room off of the wall, disassembled it, and used the metal inside of it to cut her wrist. The patient was moved to a more secure room for closer monitoring and a 1:1 sitter was assigned to the patient.

b. On 8/30/18 at 10:42 a.m., an interview with RN #4 was conducted, who worked on the inpatient psychiatric unit. RN #4 stated patients admitted to the adult psychiatric unit with suicide ideations were expected to be monitored every 15 minutes unless ordered as a 1:1 observation which meant a staff member had to be present with the patient at all times. If a patient had a suicide attempt in the hospital, the patient would be placed on a 1:1 when arriving to the psychiatric unit and given a suicide blanket (weighted blanket that could not be tied).

c. On 8/29/18 at 2:43 p.m., an interview with Behavioral Health Specialist (BHS) #5 was conducted. BHS #5 explained the physician determined the level of observation that each patient was placed on with collaboration of the unit nurses and BHS. Additionally, BHS #5 stated the ED gave the psychiatric unit nurse a report of the patient's ED visit. BHS #5 stated suicide precautions meant monitoring the patient every 15 minutes and having a heightened awareness that the patient was at risk for suicide. BHS #5 explained patients at risk for suicide attempts were always looking for a way to harm themselves and were sick; therefore, it was important for staff to always keep them in their line of sight and to provide a safe environment.

d. On 8/29/18 at 4:52 p.m., an interview with Behavioral Health Director (Director) #8 was conducted. After reviewing Patient #9's visit, Director #8 explained the patient was located in a medical ED patient room at the time the patient accessed the betadine. Director #8 did not have an answer as to how the patient was able to have access to a bottle of betadine, but stated the bottle should have been removed from the room. Director #8 further stated she could not speak to how Patient #9 had access to the bottle of betadine when she was ordered to be on a 1:1 level of observation. She added she was unable to find any documentation on how Patient #9 was monitored while in the ED.

On 8/30/18 at 11:44 a.m., an additional interview was conducted with Director #8 and the Director of Quality and Safety (Director #18). Director #8 stated her expectation was for staff on the inpatient psychiatric unit to observe patients on suicide precautions more closely in order to identify issues to avoid a successful suicide attempt. Director #8 stated patients on the psych unit had greater levels of change and suicide risks and felt the unit was monitoring patients appropriately because there had not been a "successful" suicide attempt on the unit.

Director #8 then stated during the facility's investigation of Patient #9's incidents of self harming and suicide attempt, the facility identified the soap dispensers located in patient rooms as a safety risk. Director #8 further stated the facility identified the patient should have been on a 1:1 level of observation when she arrived to the inpatient psychiatric unit. Director #18 added there could have been a lack of communication to the psychiatric inpatient staff about the patient's capability for self harm. If the inpatient staff had been made aware of the patient's prior self harming actions, Director #18 stated the information could have played a role in the decision making when determining if the patient needed to be on a 1:1 level of observation. Director #18 then stated there had been discussions after the incidents; however, there was no documentation of the discussions or if there had been any education to staff and changes implemented to ensure a similar incident would not reoccur.

4. The facility failed to assess and identify environmental safety risks in patient care areas throughout the hospital to protect patients at risk of self harm, specifically ligature risk.

a. On 8/27/18 at 3:00 p.m., a tour of the adult and senior psychiatric units was conducted. Inspection of both units revealed multiple ligature risk door handles outside of offices and non-patient rooms which were located in open hallways where patients were observed walking. Additionally, the senior psychiatric unit rooms had rolling beds with side rails which were not ligature resistant and long cords connecting the beds to the wall.

b. On 8/27/18, the day the survey team entered the facility, a spreadsheet was provided. The spreadsheet included identified ligature risks found throughout the facility and the facility's mitigation plan. The facility reported the spreadsheet had not been completed until mitigation plan was requested by surveyors.

c. On 8/30/18 Director #8 provided Environmental Risk Assessments, for the Adult/Senior psychiatric units as well as the adolescent psychiatric units. According to the documentation, the assessments were conducted in October 2017 and April 2018. Review of the documentation revealed the facility did not identify the rolling beds with side rails which were located in the senior psychiatric unit as a ligature risk. Further review of the documentation revealed items which were identified as a ligature risk, but had no mitigation plan. As example,

On the risk assessment, dated 4/16/18, the section which asked "Is patient room furniture secured to prevent it being used to block access or otherwise cause harm?" was checked as "Yes." However, there was no documentation the facility had identified and provided a mitigation plan for the rolling hospital beds on the senior psychiatric unit.

For the section which asked "Are hinges, handles, knobs, fixtures, etc. constructed in such a way that they don't present a ligature risk?" both yes and no were checked. Under the comments it was noted the patient rooms had safe knobs but others in open halls may not. However, there was no mitigation plan put in place for the identified ligature risk.

d. On 8/30/18 at 2:20 p.m., an interview with the Behavior Health Training and Compliance Coordinator (Coordinator #7) was conducted. Coordinator #7 explained he and Director #8 performed a ligature risk assessment of the psychiatric units most recently last spring. Coordinator #7 stated there were areas on the adult and senior units which posed a risk to patients if left alone such as hallways and bathrooms with elongated door handles. Coordinator #7 also identified long cords that were observed on the senior side. Coordinator #7 stated all risks could not be removed, therefore, staff were expected to increase rounding for patient safety.

5. The facility failed to ensure patients were monitored according to physician orders in 3 of 7 patient records who had 1:1 monitoring ordered (Patients #7, #9, and #10).

a. Review of the History of Present Illness (HPI) located in Patient #9's medical record revealed the patient presented to the emergency department (ED) on 4/8/18 at 10:24 a.m. after trying to kill herself by ingesting seven Xanax (antianxiety) pills, blood pressure medications and alcohol. At 10:49 a.m., an order to notify security to implement 1:1 monitoring was placed; however, there was no documentation to show the 1:1 monitoring was in place. At 3:14 p.m., nursing documentation revealed the patient attempted to drink betadine solution (a topical antiseptic used to kill bacteria, fungi and viruses) while in her ED room. Approximately 15 milliliters (ml) were missing from the bottle and the patient had betadine on her clothes.

b. Review of Patient #7's medical record revealed RN #9 documented a nursing note on 5/18/18 at 5:35 p.m. The RN documented around 3:30 p.m., BHS #21 reported Patient #7 hit her on the chest while she was providing the patient care. Further documentation revealed the patient was difficult to redirect.

Review of written physician orders showed, on 5/18/18 at 4:00 p.m., 1:1 observation was ordered for safety. The Precaution Check List for 5/18/18 showed no evidence the patient was monitored 1:1 after assaulting BHS #21.

On 5/19/19 at 3:03 p.m., RN #9 documented around 2:00 p.m., Patient #7 was sitting in the day hall rubbing his knee and suddenly got up and knocked the cup from another peer's hands and started punching the other peer in his back several times for no apparent reason. There was no documentation indicating Patient #7 was on 1:1 monitoring when the assault happened.

c. Review of Patient #10's medical record showed 1:1 observation was ordered on 12/16/17 and discontinued on 12/24/17 at 3:30 p.m. The Precaution Check Lists dated 12/22/18 and 12/23/18 had no evidence which showed Patient #10 was observed according to physician order.

d. On 8/30/18 at 11:06 a.m., an interview was conducted with RN #9 who was responsible for providing care to patients on the senior psychiatric unit and adult psych unit. RN #9 stated 1:1 monitoring meant 1 staff member to 1 patient. She said the Precaution Check List form should indicate there was 1:1 monitoring.

A review of Patient #7's Precaution Check List forms was conducted. After review, RN #9 confirmed there was no documentation which indicated who was assigned the 1:1 or that the 1:1 monitoring was completed. She stated the form dated 5/18/18 only indicated the location and behavior of the patient every 15 minutes. RN #9 reported Patient #7 was very challenging. She stated the patient had dementia and was assaultive in the unit. She further stated the patient required a lot of redirection.

RN #9 stated the purpose of 1:1 monitoring was for safety. She stated patients who were placed on 1:1 observation for assaults were potentially violent and could harm other patients and staff members. RN #9 explained there were behaviors staff could observe before the patient escalated and staff could intervene right away to prevent an incident. RN #9 stated the 1:1 documentation could also be charted in the shift assessment. Review of Patient #7 and #10's shift assessments showed no evidence of the missing 1:1 monitoring documentation.

e. On 8/29/18 at 1:42 p.m., an interview was conducted with BHT #10 who provided patient care on both the adult and senior psychiatric units. BHT #10 stated for 1:1 monitoring, the staff member who was with the patient documented the 1:1 monitoring on the Precautions Check List. She further stated the sheet should indicate the time the intense 1:1 precautions started and ended.

BHT #10 reported if a 1:1 patient had to use the bathroom, the door should not be closed if the 1:1 was ordered for suicide precautions because staff needed to be able to see the patient.

f. On 8/29/18 at 2:43 p.m., an interview was conducted with BHS #5 who worked as needed in the adult, adolescent and senior psychiatric units. She stated the Behavioral Health Specialists (BHS) were mostly responsible for the 1:1 monitoring. She said the 1:1 was intense monitoring for patients who were assaultive, suicidal or were a danger to themselves or someone else. She stated staff would have to be within arm's length at all times. BHS #5 reported the intense 1:1 would be documented on the Precautions Check List form at the top. She stated the time the 1:1 started would be documented.

g. On 8/30/18 at 8:29 a.m., an interview was conducted with BHS #11. She stated 1:1 monitoring meant the staff member assigned to the patient was at arm's reach at all times to make sure the patient could not hurt themselves or others. BHS #11 stated the Precautions Check List should be labeled at the top indicating the patient was 1:1 observation.

6. The facility failed to ensure contraband (items not allowed on the unit), specifically drawstrings were removed from patient care.

a. On 8/29/18 at 7:38 a.m., a tour was conducted of the adolescent psychiatric unit. During the tour a pair of shorts with a drawstring in the waistband was observed folded on a table in room 6.

On 8/29/18 at 8:31 a.m., during the tour of the adolescent psychiatric unit an interview with Registered Nurse (RN) #19, who was in charge of unit, was conducted. RN #19 stated shoe strings and drawstrings in clothing were not allowed because patients could harm themselves. RN #19 explained belongings were inventoried on admission to remove items identified as contraband such as drawstrings. RN #19 stated the reason the drawstring remained in the shorts was because the person who inventoried the patient's personal belongings wasn't paying attention when they were performing the task, therefore they did not remove the contraband.

b. According to the History of Present Illness (HPI) documented on 6/24/18 by Physician #1, Patient #3 went to the emergency department (ED) after she attempted suicide by overdosing on Clonazepam (sedative to treat panic disorder or anxiety). While in the ED, registered nurse (RN) #6 documented Patient #3 ran into the hallway and placed a plastic bag over her head then rubbed her wrists on the door trim in an attempt to cut her wrists. She was admitted to the adult psychiatric unit around 8:15 p.m. and placed on suicide precautions for suicide ideation, severe depression and poor judgement. On 6/25/18 at 7:50 p.m., approximately 24 hours after admission, RN #2 documented Patient #3 stated she wanted to kill herself and scratched her neck with the lead end of a pencil and was actively suicidal. Patient #3 was then searched for contraband in which drawstrings were found in her pants and removed. At 9:10 p.m., Patient #3 was found hanging from the bathroom door handle with her shirt wrapped tightly around her neck. According to the policy, Patient #3's belongings should have been inventoried in the ED, when she was discharged from the ED and when she was admitted to the adult psychiatric unit.

c. On 8/29/18 at 2:43 p.m., an interview with BHS #5 was conducted. BHS #5 stated suicide precautions meant performing safety checks every 15 minutes and having a heightened awareness the patient was at risk to attempt suicide. BHS #5 explained that a patient on suicide precautions was sick and always looking for a way to carry out their impulses. Therefore, BHS #5 stated her job was to provide a safe environment because the patients did not know what was best for themselves. BHS #5 explained the staff performed rounds every shift in which they looked for contraband items such as plastic bags, drawstrings, plastic utensils and anything else the patients could use to hurt themselves. Furthermore, BHS #5 stated if contraband was missed during rounds, she felt it would be identified during the 15 minute safety checks. BHS #5 explained clothing was one of the biggest risks for hiding contraband, so staff removed drawstrings from pants and hoodies and had patients empty their pockets. Additionally, BHS #5 stated drawstrings were a risk not only to the patients that had them, but for other patients looking for an opportunity to harm themselves. BHS #5 further stated patients would not have the opportunity to use drawstrings as a ligature risk if staff were performing their jobs.

d. On 8/30/18 at 2:20 p.m., an interview with Behavioral Training and Compliance Coordinator (Coordinator #7) was conducted. Coordinator #7 stated drawstrings in clothing was considered contraband on all psychiatric units. Coordinator #7 further explained the reason to remove contraband items such as drawstrings from the unit was for patient safety to prevent all patients from using the drawstring to harm themselves, not just the patient the drawstring belonged to, but their neighbors as well. Coordinator #7 stated all staff received education regarding ligature risk mitigation. Specifically, he stated the importance of rounding to remove environmental hazards. Additionally, Coordinator #7 stated all risks could not be removed, therefore, staff were expected to increase observation for patient safety.

7. The direct patient care staff failed to monitor behavioral health patients via fifteen minute monitoring checks.

a. A review of Patient #10's medical record was conducted. Per the physician note dated 12/18/17 the patient exhibited signs of self harm by turning over tables and hitting her head. The Precaution Check List (form), which was the form used to monitor patients every fifteen minute, dated 12/24/17 had no documentation from 10:30 p.m. to 11:30 p.m. The form dated 1/3/18 revealed a total of one hour, from 10:30 a.m. to 11:30 a.m. in which there was no documentation of the fifteen minute monitoring checks.

b. A review of Patient #3's medical record was conducted. Patient #3 was admitted for major depression and indifference for life. The History and Physical dated 6/24/18 documented Patient #3 would be on suicide precautions for safety monitoring and orders showed Patient #3 would be on 1:1 observation. Review of the form for 6/26/18 showed from 6:45 a.m. to 7:30 a.m. in which there was no documentation of fifteen minute monitoring checks or 1:1 observation.

c. A review of Patient #6's medical record was conducted. Patient #6 was admitted to the facility with a diagnosis of schizophrenia and had been placed on suicide, assault, and elopement precautions. On 4/3/18 the form had no documentation of fifteen minute safety checks from 6:15 a

Based on interviews and document review, the facility failed to ensure patients placed in physical restraints and seclusion were monitored and assessed according to the facility's standards in 1 of 1 patient's medical record reviewed for restraint/seclusion (Patient #6)

Findings include:

1. The facility failed to ensure staff monitored and assessed Patient #6 while in restraints and seclusion to ensure the patient's emotional and physical needs were met.

a. According to the Restraint and/or Seclusion Flow Sheet used for violent patients, the following interventions needed to be done every two hours and as needed: reposition, reorientation, range of motion and skin integrity check.

Review of Patient #6's physician orders showed on 4/7/18 at 9:10 p.m., seclusion and four point restraints were ordered because the patient repeatedly punched himself and slammed his head on the floor.

Review of Patient #6's restraint and seclusion flowsheets revealed on 4/7/18 from 8:00 p.m. until the patient was released from restraints and seclusion at 11:55 p.m., there was no evidence the patient's extremities were checked for skin integrity. Additionally, there was no evidence on the flow sheet which indicated the patient was reoriented, repositioned or range of motion to the restrained extremities were done during the four hour period.

On 4/12/18 at 6:12 a.m., Patient #6's physician ordered four point restraints per patient request to feel safer.

Review of Patient #6's restraint and seclusion flowsheets revealed on 4/12/18, the patient was in seclusion and restraints from 5:55 a.m. until 10:30 a.m. There was no evidence on the flow sheet which showed the patient was offered fluids or toileting during the four hour period. According to the observed behaviors documentation, the patient was awake. Furthermore, there was no evidence the patient's skin integrity was checked at the point of restraint.

According to the physician order dated 4/12/18 at 4:40 p.m., four point restraints were ordered after the patient became agitated and swiped at security. At 9:06 p.m., an order was entered to continue restraints due to patient being uncooperative. A third order was entered on 4/13/18 at 12:30 a.m. for continued restraints for self harm.

Patient #6 was placed in seclusion and restraints for a second time on 4/12/18. According to the flowsheet dated 4/12/18, the second episode began at 4:28 p.m. and was discontinued on 4/13/18 at 4:20 a.m.

From 4:28 p.m. until 11:20 p.m., there was no evidence the patient was offered fluids. According to the nurse noted documented at 11:20 p.m., the patient was offered food and fluids and skin integrity was checked. However, during the first 7 hours of restraint and seclusion, there was no evidence nursing staff provided reorientation, range of motion exercises or conducted skin integrity checks every 2 hours according to the flowsheet guidelines. From 12:15 a.m. until 4:20 a.m., after the patient went to the bathroom at midnight and was offered water, there was no evidence of skin integrity checks, range of motion or patient orientation being provided.

b. On 8/30/18 at 2:20 p.m., an interview was conducted with Behavior Health Training and Compliance Coordinator (Coordinator) #7 and Behavioral Health Director (Director) #8. Coordinator #7 stated patients in restraints were to have 1:1 monitoring. He stated activities of daily living should be on schedule and skin integrity should be monitored by the patient's nurse.