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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's Rights, was out of compliance.

A-0144 - The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patients who were on suicide precautions did not have access to excessive linen and other items that could be used to cause harm in five of five observations conducted at the facility. Additionally, the facility failed to ensure patients were monitored for safety and as ordered by the provider in one of five observations conducted at the facility.

Based on observations, interviews, and document review, the facility failed to ensure patients who were on suicide precautions did not have access to excessive linen and other items that could be used to cause harm in five of five observations conducted at the facility. Additionally, the facility failed to ensure patients were monitored for safety and as ordered by the provider in one of five observations conducted at the facility.

Findings include:

Facility policies:

The Behavioral Health General Safety Policy read, all corded appliances are stored in a locked cabinet. Patients may use appliances under staff supervision. Patient rounds are done minimally every 15 minutes 24 hours per day. Environmental Rounds will be completed twice a day. The Nurse Manager will determine when the checklist will be done and indicate the responsible person. Anything found during Environmental Rounds that is not in compliance or suggests a safety concern should be reported to the Charge Nurse and then reported to the appropriate designee.

The Behavioral Health Levels of Observation and Precautions policy read, all patients are monitored a minimum of once every fifteen minutes. This is documented on the Patient Monitoring Form, including the patient's location and status/behavior/activity.

The Behavioral Health Patient Safety Rounds and Validation policy read, the Clinical Nurse Coordinator (CNC)is responsible for assigning staff to make unit rounds to account for all patients' whereabouts and ensure a safe environment. If the staff member observes the environment for unsafe conditions or significant behavioral observations of patients they will be reported to the CNC immediately.

1. The facility failed to identify and mitigate ligature risks for patients with suicidal ideations. Additionally, the facility failed to remove contraband that the patient could use for self-harm.

A. Observations

i. On 7/22/24 at 1:28 p.m., observations were conducted on the adolescent psychiatric unit in room 1010. The observation revealed Patient #1 had six blankets, two fitted sheets, three towels, and two washcloths in their room.
Review of Patient #1's patient monitoring form showed the patient was on 15-minute checks for suicide precautions.
Further observations of the adolescent psychiatric unit revealed multiple piles of unsupervised dirty linen in the hallway and patient care areas.

ii. On 7/22/24 at 2:10 p.m., observations were conducted on the adolescent psychiatric unit. Observations in the day room revealed a media cabinet unlocked and open. Further observations inside the cabinet revealed multiple electronic cords for media and game systems.

iii. On 7/24/24 at 12:45 p.m., additional observations were conducted on the adolescent psychiatric unit day room. Observations in the day room again revealed a media cabinet unlocked and open. Further observations revealed multiple electronic cords for media and game systems. Staff were unable to answer who opened the cabinet and how long it had been open. Staff were also unable to answer if any of the cords were missing.

iv. On 7/24/24 at 1:09 p.m., observations were conducted on the adolescent psychiatric unit in room 1006. Observations revealed Patient #1 had been moved from room 1010 to this room, which was closer to the nursing station. Further observations revealed the patient had three blankets in their room.

Review of Patient #1's patient monitoring form showed the patient was on 15-minute checks for suicide precautions.

v. On 7/25/24 at 12:39 p.m., observations were conducted on the adult psychiatric unit in room 1016. Observations revealed Patient #2 had a tongue piercing with a silver barbell. Patient #2 stated they were admitted for suicidal ideation and, in prior admissions, they were not allowed to have their tongue pierced for their safety. Patient #2 stated they were upset that the staff had just removed all of their blankets from their room and gave them an anti-suicide blanket (tear-resistant blanket used to prevent the patient from forming a noose to attempt suicide).

Review of Patient #2's patient monitoring form showed the patient was on 15-minute checks for suicide precautions.
This observation was in contrast to the observations on 7/22/24 at 1:28 p.m. where Patient #1 had multiple standard hospital blankets and was also on 15-minute checks for suicide precautions.

B. Document Review

i. Medical record review revealed Patient #1 was admitted on 7/21/24 to the adolescent psychiatric unit for schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and suicidal ideation. Further review of the medical record revealed the patient scored ten out of ten for suicidal ideation on the daily self-assessment. According to the self-assessment instructions, a ten meant the symptoms were present at the greatest possible level. Further review of the self-assessment revealed the documentation was missing the date completed and the signatures of the nurse, social worker, and provider.

ii. Medical record review revealed Patient #2 was admitted on 7/25/24 to the adult psychiatric unit for suicidal ideation. Further review of the medical record showed the provider did not place a privilege order that allowed the patient to have a facial piercing. Additionally, Patient #1 did not have a contract for safety for facial piercings.

C. Interviews

i. On 7/22/24 at 2:02 p.m., an interview was conducted with Tech #1. Tech #1 stated Patient #1 was admitted for suicidal ideation and was unaware that Patient #1 had excessive linens in their room. Tech #1 stated patients at risk for suicide should not have had extra linens in their rooms. Tech #1 stated the extra linens in the patient care area increased the patient's ligature risk (the potential for someone to use a cord, rope, or other material to attach themselves to something for the purpose of hanging or strangulation).

ii. On 7/24/24 at 2:50 p.m., an interview was conducted with Tech #1. Tech #1 stated they were not aware the media cabinet was open and patients had access to the electronic cords. Tech #1 stated the media cabinet should have been locked and secured at all times. Tech #1 stated the electronic cords were a ligature risk. Tech #1 stated if the cabinet was unlocked, the patients could have gained access to the electronic cords and harmed themselves or other patients.

iii. On 7/22/24 at 2:44 p.m., an interview was conducted with RN #2. RN #2 stated patients on the psychiatric unit should not have had access to extra linens. RN #1 stated patients were only allowed to have a maximum of two blankets in their room. RN #2 stated extra linens in the patients' rooms increased the patients' ligature risk. RN #2 stated it was the Techs' responsibility to identify the ligature risk during their environmental rounds, mitigate the risk by removing the extra linens, and report back to the nurse.

iv. On 7/24/24 at 2:55 p.m., an interview was conducted with RN #4. RN #4 stated the media cabinet in the day room should have been locked at all times. RN #4 stated the media cabinet contained electronic cords for the TV and video game systems. RN #4 stated they were unsure of how long the cabinet was open and unsecured. RN #4 stated that it was important to secure the media cabinet to prevent patients from gaining access to ligature contraband. RN #4 stated patients were at risk of strangulation and death if they had access to ligature contraband such as electronic cords.

v. On 7/25/24 at 2:46 p.m., an interview was conducted with the manager of the adult unit (Manager) #3. Manager #3 stated Patient #2 was admitted for suicidal ideation. Manager #3 stated Patient #2 did not have the facial piercing noted on their personal belonging sheet. Manager #3 stated the patient needed to have a privilege order from their provider and a contract for safety before they were allowed to have any jewelry, including facial piercings. Manager #3 stated patients who had access to jewelry could cause self-harm or injure other patients.

2. Staff failed to consistently perform 15-minute checks on high-risk psychiatric patients, which increased the patients' risk of injury.

A. Observations

i. On 7/24/24 at 2:02 p.m., observations were conducted on the geriatric psychiatric unit in room 3003. Patient #3 was found lying in bed in a supine position (when a person lies on their back) with their urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) tubing stretched. Patient #3's urinary catheter bag was found attached to the patient's unlocked wheelchair. Further observation revealed the urinary catheter bag was attached to the bottom of the wheelchair seat, allowing the urinary bag to be dragged across the floor. Patient #3 stated their lower stomach hurt and that they felt like they needed to urinate. Patient #3 stated they did not remember how they got into bed.

Staff on the geriatric psychiatric unit stated they did not transfer Patient #3 into their bed.

ii. Observation of the surveillance video revealed on 7/24/24 at 12:50 p.m. Patient #3 wheeled themselves to their room. Patient #3's urinary catheter bag was hanging off of the bottom of the wheelchair and dragged across the floor. At 1:06 p.m., Tech #5 was seen walking in and out of Patient #3's room with a clipboard used to document 15-minute checks. At 1:36 p.m., 30 minutes after the patient's last 15-minute check, Tech #5 was seen briefly walking in and out of Patient #3's room with a clipboard to document 15-minute checks. At 1:58 p.m., 22 minutes after the patient's last 15-minute check, a nurse was seen briefly walking in and out of Patient #3's room with a clipboard to document 15-minute checks.

This observation was in contrast to Patient #3's patient monitoring form, which documented Tech #5 observed Patient #3 resting in bed at 1:00 p.m., 1:15 p.m., 1:30 p.m., 1:45 p.m., and 2:00 p.m.

This observation was in contrast to the Behavioral Health Levels of Observation and Precautions policy, which stated all patients were to be monitored a minimum of once every fifteen minutes. This needed to be documented on the Patient Monitoring Form, including the patient's location, status, behavior, and activity.

B. Document Review

i. Review of Patient #3's medical record revealed the patient was a fall risk. Further review of the medical record revealed the patient had an order for the staff to assist with all transfers.

ii. Review of Patient #3's patient monitoring form revealed Tech #5 documented the patient was in bed at 1:00 p.m., 1:15 p.m., 1:30 p.m., 1:45 p.m., and 2:00 p.m.

This was in contrast to the surveillance video footage, which showed Tech #5 entered and exited the room at 1:06 p.m. and 1:36 p.m.

C. Interviews

i. On 7/24/24 at 3:50 p.m., an interview was conducted with Tech #5. Tech #5 stated Patient #3 was a fall risk and required assistance to transfer. Tech #5 stated Patient #3 was on a 15-minute check for their risk of falls. Tech #5 stated they visually checked on Patient #3 every 15 minutes between the hour of 1:00 p.m. and 2:00 p.m. Tech #5 stated 15-minute checks were important for the safety of the patients. Tech #5 stated if 15-minute checks were not performed, the patient could fall or cause self-harm.

This interview was in contrast with the surveillance video footage, which showed Tech #5 entered and exited the room at 1:06 p.m. and 1:36 p.m.

ii. On 7/24/24 at 3:00 p.m., an interview was conducted with the executive director (Director) #6. Director #6 stated that 15-minute checks were standard practice for all psychiatric patients admitted to the facility. Director #6 stated 15-minute checks were important for the safety of the patients. Director #6 stated if staff did not perform 15-minute checks, patients would be at risk for falls, self-harm, or carrying out suicidal or homicidal ideations.

3. The facility failed to ensure that staff could quickly and easily gain access to psychiatric patients in their rooms. Specifically, the facility failed to maintain functional locks on patient care area doors to provide unobscured access to psychiatric patients.

A. Observations

i. On 7/24/24 at 1:14 p.m., observations were conducted on the adult psychiatric unit. The observations revealed that loud noises could be heard from outside the door of room 1055. Manager #3 had attempted to gain access to the room; however, the door handle was stuck in a locked position. Manager #3 had attempted to use their key to unlock the door without success. Manager #3 knocked on the door, and Patient #4 was able to open it from the inside handle. Patient #4 stated that the door needed to be locked to keep out the evil spirits. Patient #4 stated the other patients on the unit would not be ready to see them and what they were capable of. Manager #3 instructed the staff to place a work order immediately to repair the lock for patient safety.

This observation was in contrast to the work order log, which revealed the work order was placed at 3:42 p.m., two hours and 28 minutes after the lock malfunction was identified.

B. Document Review

i. Medical record review revealed Patient #4 was admitted on 7/16/24 to the adult psychiatric unit on an M1 Hold (an involuntary 72-hour emergency mental health hold placed on a patient determined to be at risk of self-harm, harming others, or gravely disabled) for psychosis and grave disability. Review of Provider #9's progress note entered on 7/24/24 at 2:36 p.m. revealed Patient #4 experienced auditory hallucinations. Further review of the progress note revealed the provider was unable to predict the patient's behavior, including whether the patient would attempt to harm themselves or others. Provider #9 stated both violent acts and suicide attempts were difficult to predict, given the combination of intervening changing life circumstances outside of a clinician's control and the fact that many individuals only considered violence or suicide for minutes to hours prior to acting.

ii. A review of the maintenance work order log number 8049998 revealed that a critical status work order was entered on 7/24/24 at 3:42 p.m. for room 1055. The work order reported the door lock to room 1055 malfunctioned and needed immediate replacement.

This was in contrast to the observations on 7/24/24 at 1:14 p.m. when Manager #3 informed their staff to immediately place a work order to repair room 1055's malfunctioned lock.

iii. A review of maintenance work order log number 7968927 revealed that a standard status work order was entered on 7/5/24 at 8:12 a.m. without specifying the room number. The work order noted that a patient's door lock malfunctioned, posing a safety concern as it would delay staff access to the room.

C. Interviews

i. On 7/24/24 at 1:27 p.m., an interview was conducted with Tech #8. Tech #8 stated patients should never have been left alone behind a locked door. Tech #8 stated that if the door lock had malfunctioned, the staff could have been delayed in reaching the patient, and the patient could have harmed themselves or others.

ii. On 7/29/24 at 1:36 p.m., an interview was conducted with RN #7. RN #7 stated if a patient's lock had been malfunctioning, they would have immediately moved the patient to another room and put in a work order. RN #7 stated they would have made sure that room was not used. RN #7 stated if the door to the patient's room malfunctioned and had been locked, the patient could have strangled themselves or caused self-harm.