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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure items considered hazardous to a suicidal patients were removed from a patient's room on the Behavioral Health Unit (BHU) resulting in a suicidal patient being able to use a shower chair to hang self in the patient room bathroom shower.Following removal of the patient room bathroom shower doors on January 9, 2021, the facility did not address the sharp metal protrusions from the removal of the screws and hinges.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP8 and EMP9) regarding the survey team's concerns related to Patient's Rights on January 15, 2021 at approximately 1:05 PM.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services
482.23 (a) Organization of Nursing Services

Based on review of facility documents, medical record (MR1) and staff interview (EMP), it was determined the facility failed to remove a shower chair from a patient's room on the Behavioral Health Unit (BHU) following a shower; the facility failed to identify the shower chair as a risk and remove the shower chair during the Unit Safety Check Monitor Rounds; the facility failed to identify the hinges on bathroom doors in patients' rooms on the BHU as ligature risks prior to the hanging incident and, the facility failed to ensure the door jambs were free of sharp metal protrusions following removal of 20 bathroom doors in the BHU.

Findings include:

Review on January 15, 2021, of the facility's "Patient Rights and Responsibilities" policy, last approved June 13, 2018, revealed "Policy: At Robert Packer Hospital, we encourage respect for the patient's personal preferences and values of each individual. We consider the patient a partner in their hospital care. When a patient is well informed, participates in treatment decisions, and communicates openly with their doctor and other health professionals, they help make their care as effective as possible. Hospital personnel, medical staff, and contracted staff performing patient care must observe these patients' rights. ... Patient Rights: ... 9. You have the right to receive care in a safe setting ..."

Review on January 15, 2021, of the facility's "Unit Safety Check" policy, last approved August 3, 2020, revealed "Policy: Robert Packer Hospital's Behavioral Sciences Center ensures the safety and security of the Behavioral Health Unit on all shifts. Staff will use the "Unit Safety Check Monitor" form to serve as a monitoring tool for safety. Procedure: Process Definitions: Visual check of patient areas for restricted items. A walk-through of patient areas, including patient rooms, patient bathrooms and showers, to visually check for restricted items. This is not a room/unit search, but a visual check. Electrical equipment check. A visual check of electrical equipment or appliances to identify frayed cords or devices that may be "missing". Housekeeping equipment check. A visual check to assure that equipment is not left unattended during day shift and on nights. On evenings a visual check performed to assure that equipment is located in locked area(s). Door check. All doors listed on the Unit Safety Check Monitor are to be assessed to assure they are locked when not in use. Stairwell Door. The stairwell door is locked at all times. 1. A Behavioral Health Unit staff member is assigned to complete unit safety checks, using the Unit Safety Check Monitor form, daily, up to every 8 hours. The frequency of completion is adjusted based on acuity and safety need..."

Review on January 15, 2021, of the facility's "Behavioral Health Services In-patient Unit Unit Safety Check Monitor - Day/Eve/Night Shifts" form, no review date, revealed documentation instructing BHU staff to complete a visual check of patient areas for restricted items. These areas included: patient lockers, patient care areas for restricted items; the refrigerator and freezer temperatures; door props; unattended computers; hallway clearance; linen hampers are emptied; housekeeping equipment not left unattended; the nursing station clean and orderly; fire alarm pull stations free from obstruction; staff food and drinks removed from patient care areas; all medication is secured; staff wearing badges; patient information is properly discarded; portable equipment is washed down; all security alarms are accounted for; no damage to ceiling tiles; nothing stored under sinks; kitchen area clean; sprinkler heads clean; code cart check and doors locked in the following areas: stairwell, intensive care area, medication room. Housekeeping closet, clean and dirty utility rooms, the laundry room, community and family rooms, all offices, and doors leading to the patio, emergency exit, group room and dining room.

Review on January 15, 2020, of the facility's "Environmental Risk Reduction Policy," last approved December 31, 2019, revealed "Policy This policy applies to patients who have been identified to be at risk for suicide. The goal of this policy is to eliminate or reduce the frequency, magnitude, or severity of exposure to risks, or minimization of the potential impact of harm. Scope This policy applies to all staff/personnel that are responsible for the care of the patient identified at risk for suicide. Definitions A. Ligature - an object used for tying or binding something tightly. B. Environment - the surroundings or conditions in which a person interacts. Personal possessions are included as part of the environment in terms of this policy. Procedure ... B. Behavioral Sciences Center (BSC) ... D. Multidisciplinary Suicide/Ligature risk Assessment a. Once a year, starting in January, an RPH [Robert Packer Hospital] multidisciplinary team (including but not limited to clinical, patient safety, maintenance, security, quality, etc.) will conduct a safety assessment to further manage the risks associated with suicide assessment in identified patient care areas. ... b. This safety assessment should identify potential hazards such as those that may be used for self-harm, harm to others, or ligatures. ..."

Review on January 15, 2021, of the facility's "Safety Risk Assessment Robert Packer Hospital Behavioral Sciences Center" completed August 20, 2020, revealed "Historically, a Safety Risk Assessment (SRA) has been a methodical process for identifying and managing threats in an identified area. In this case, the Behavioral Sciences Center and acute inpatient behavioral health unit of the Robert Packer Hospital (RPH; Sayre, PA) is the identified area for assessment. The SRA involves a thorough examination of the entire work environment, processes and equipment to determine hazards to the health of the patients served and employees who serve the patients in the behavioral health population. The goal of the assessment is to identify ligature risks and develop short and/or long-term remedies and resources to improve ligature risk assessment and mitigation to identified findings. ... Remediation Score ... (High) a patient is at risk when extended intervals of privacy are given to our patients in areas where there is no camera surveillance. - Typical high-risk areas house patients who are difficult to manage. The risk of solitary and/or unsupervised use of areas such as Patient Bedrooms with Bathrooms, calls for special care to be taken on the unit ... Doors and Locksets ... Bathroom doors have been removed or fashioned with a sloped top. ..."

1. Review of MR1 on January 15, 2021, revealed this patient was admitted to the facility on January 6, 2021, following an attempted suicide by self-inflicted stab wounds to the abdomen, left wrist and left forearm with a knife. MR1's physician ordered constant 1:1 observation from January 6 through January 8, 2021. On January 8, 2021, MR1's physician discontinued the constant 1:1 observation and ordered MR1 on every 15-minute observation checks.

Interview with EMP1 and EMP2 on January 15, 2021, at approximately 4:20 PM confirmed MR1 was admitted to the facility following an attempted suicide by self-inflicted stab wounds to the abdomen, left wrist and left forearm with a knife at home; MR1 was on constant 1:1 observation from January 6 to 8, 2021, when MR1's observation status was changed to every 15-minute observation checks.

Review of MR1 on January 15, 2021, revealed on January 8, 2021, MR1 asked to take a shower. BHU staff provided MR1 with a shower chair at 4:00 PM.

Review of MR1 on January 15, 2021, revealed nursing documentation dated January 9, 2021, at 6:45 PM that MR1 was found in the patient room bathroom shower with the top sheet from the bed wrapped around the neck hanging from the bathroom door jamb. The shower chair was found at MR1's feet. MR1 hung for approximately five minutes and had loss of consciousness.

Interview with EMP1 and EMP2 on January 15, 2021, at approximately 4:50 PM confirmed the nursing documentation that MR1 was found in the patient room bathroom shower with the top sheet from the bed wrapped around the neck hanging from the bathroom door jamb; the shower chair was found at MR1's feet; MR1 hung for approximately five minutes and had loss of consciousness.

Interview with EMP1, EMP2 and EMP3 on January 15, 2021, at approximately 4:55 PM revealed MR1 took the top sheet from the bed, wrapped it around the neck, stood on the shower chair, placed the sheet on the upper door hinge, between the bathroom door and door jamb and hung self. EMP1, EMP2 and EMP3 confirmed BHU staff did not remove the shower chair from MR1's patient room bathroom shower immediately after MR1's shower. EMP1, EMP2 and EMP3 confirmed the shower chair is a risk to a patient with suicide thoughts.

2. Review on January 15, 2021, of the facility's "Behavioral Health Services Inpatient Unit Safety Check Monitor - Day/Eve/night Shift" form, revealed documentation instructing BHU staff to complete a visual check of patient areas for restricted items. There is no documentation on this form instructing BHU staff to check and monitor BHU patient rooms, bathrooms or the room shower area.

Interview with EMP1 and EMP2 on January 15, 2021, at approximately 4:15 PM confirmed there is no documentation on the Behavioral Health Services Inpatient Unit Safety Check Monitor - Day/Eve/night Shift form instructing BHU staff to check and monitor BHU patient rooms, patient room bathrooms or the shower areas in the patient room bathrooms.

Review on January 15, 2021, of the "Robert Packer Hospital Behavioral Health Services Inpatient Record of Special Observation: Q15 Minutes" form, no review date, revealed a column indicting time which is broken down into 15 minute intervals and area for staff to make marks indicating where the patient is under the following heading: Nursing Station; TV Lounge; Stereo Lounge; Relax. Lounge; Dining Room; Bedroom; QIB (Quiet in Bed); AIB (Awake in Bed); Kitchen; Patio; ICA (Intensive Care Area) Other; Equipment Check.

Review on January 15, 2021, of MR1's Inpatient Record of Special Observation: Q15 Minutes form revealed this patient showered on January 8, 2021, at 4:00 PM.

Interview with EMP2 on January 15, 2021, at approximately 11:00 AM revealed BHU staff provided MR1 with a shower chair for use during the shower and BHU staff left the shower chair in MR1's shower. EMP2 revealed the shower chair was left in MR1's shower from January 8, 2021, at 4:00 PM to January 9, 2021, at 6:45 AM when MR1 was found hanging from the patient bathroom shower door.

Interview with EMP1 and EMP2 on January 15, 2021, at approximately 4:55 PM confirmed BHU staff did not remove the shower chair when MR1 was done with the shower; the shower chair was not identified and removed during the Unit Safety Check Monitor Rounds and MR1's every 15-minute Inpatient Special Observation Rounds and the shower chair is considered a hazard on the Behavioral Health Unit.

3. Review on January 20, 2021, of the facility's Safety Risk Assessment of the Behavioral Health Unit completed on August 20, 2020, revealed patient bathroom shower doors were identified as high risk due to these areas being unsupervised areas and the bathroom doors have been removed or fashioned with a sloped top.

Interview with EMP2 and EMP4 on January 15, 2021, at approximately 7:30 PM confirmed facility staff completed a Safety Risk Assessment of the Behavioral Health Unit on August 20, 2020. EMP2 and EMP4 confirmed the patient bathroom shower doors were identified as high risk due to these areas being unsupervised areas. EMP4 revealed the doors were not removed but were cut with the top of the door being slopped. EMP2 and EMP4 revealed the hinges on the bathroom shower doors were not identified as ligature risks at the time the risk Assessment was completed.

4. Observation tour of patient rooms 311, 312, 318 and 319 on the Behavioral Health Unit on January 15, 2021, at 11:00 AM revealed the doors to the patient bathroom showers were removed. Further observation revealed sharp metal protrusions on the door jambs where the screws and the door hinges were removed.

Interview with EMP2 on January 15, 2021, at the time of the observation revealed all 20 patient bathroom shower doors were removed on January 9, 2021, and the sharp metal protrusion would most likely be found on all 20 door jambs.

Interview with EMP2 and EMP4 on January 15, 2021, at the time of the observations confirmed the patient rooms 311, 312, 318 and 319 on the Behavioral Health Unit had the doors to the patient bathroom showers removed and the sharp metal protrusions on the door jambs where the screws and the door hinges were removed. EMP2 revealed the sharp metal protrusions pose a hazard for patients with suicidal thoughts.

Interview with EMP4 on January 15, 2021, at approximately 4:45 PM revealed all 20 patient bathroom shower doors were removed on January 9, 2021, and the door jambs were not checked for sharp metal protrusions when removed.

Cross reference
482.13 Patient Rights
482.23 Nursing Services
482.23 (a) Organization of Nursing Services

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Tag A-0386
The information reviewed during the survey provided evidence the nursing department failed to document an emergency response for a patient found hanging in the Behavioral Health Unit (BHU) and the facility failed to notify a patient's family regarding an attempted suicide by hanging requiring transfer to the Emergency Department (ED).

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP8 and EMP9) regarding the survey team's concerns related to Nursing Services on January 15, 2021 at approximately 5:05 PM.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization of Nursing Services

Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to document an emergency response for a patient found hanging in the Behavioral Health Unit (BHU) for one of one applicable medical record reviewed (MR1) and the facility failed to notify a patient's family regarding an attempted suicide by hanging requiring transfer to the Emergency Department (ED) for one of one applicable medical record reviewed (MR1).

Findings include:

Review on January 15, 2020, of the "Chief Nursing Officer - GHS" job description, active January 7, 2007, revealed "Position Summary Description The CNO is ultimately accountable and responsible for establishing, directing, and evaluating professional practice for nursing staff throughout the organization. The CNO is an integral member of the senior leadership team focused on strategic direction, performance improvement, clinical outcomes, financial measures, and other indicators of operational effectiveness. The CNO collaborates with senior leaders to provide direction for Nursing care throughout the System. ... Essential Functions Description 1. Is responsible and accountable for professional practice of nursing. Establishes standards for Nursing Practice and is responsible in cooperation with the director of nursing for designing the Professional Practice Model employed at each of the facilities. Defines nursing policies and procedures, and outcomes. ..."

Review on January 15, 2021, of the facility's "Emergency Resuscitation: Code Blue" policy, last approved August 27, 2018, revealed "Policy: Re-establish ventilation and circulation in the event of cardiopulmonary arrest. Equipment: 1. Crash Cart 2. Monitor/defibrillator Procedure: 1. Any nursing personnel finding a patient who appears to be having a cardiopulmonary arrest, should begin cardiopulmonary resuscitation ... 3. Code Blue activation in the outpatient setting requires rapid transportation of the patient to the Emergency Department (ED) for ongoing treatment. 4. Inpatients are transported to the ICU as soon as return of spontaneous circulation (ROSC) is obtained. Code Blue Team members A. Nursing Floor Personnel 1. Obtain venous access / ensure venous access patency. 2. Document on code sheet 3. Assist with the preparation, administration and documentation of medications 4. Cardiopulmonary resuscitation (CPR) per AHA ..."

Review on January 15, 2021, of the facility's "RPH Pacemaker/Code Record" dated September 2005, revealed space for the patient's name; date; type of arrest cardiac or resp; arrest witnessed or unwitnessed; location of code; time called; time of team arrival; code status verified. Time airway established; the times for drug administration; bolus or gtt dose, Rhythm, Defib joules, CPR / pacing in progress and vital signs. On the bottom of the sheet there are lines for other notes or test results, any line placed during the code; any procedures completed, if the patient was transferred to ICU, ER or death, the time of death. The time the attending physician and family were notified and who notified them, and there are lines for the signatures for the physician, RN recorder and Nurse Manager/Clinical Coordinator.

Review on January 15, 2021, of the facility's "Rapid Response Team" policy, last approved March 20, 2020, revealed "Applies to: Intensive/Coronary Care A Rapid Response Team (RRT) is designed to intervene and provide emergency assessment and care to patients in non-ICU settings prior to the development of cardiopulmonary arrest. ... RRT Members: 1. ICU Charge Nurse 2. Charge Respiratory Therapist 3. On-call 3rd Year Medical Resident the surgical residents, phlebotomy, and the Clinical Supervisor will be notified as well. Team Activation: The RRT may be activated by any professional staff working outside the ICU. ..."

Review on January 15, 2021, of the facility's "Rapid Response Team (RRT) Documentation Form" dated September 2005, revealed a place for physician notification, RRT notification and response date and time. The reason for the RRT activation due to being worried about the patient, acute respiratory distress or threatened airway, and acute change in the heart rate or blood pressure or an acute change in level of consciousness. Interventions that were implemented such as oxygen, chest x-ray, suction, nebulizer treatment, an EKG, laboratory work, intravenous therapy and medication administration. There is a section identified as Patient Outcome which documents if the patient was stabilized, required transfer to a higher level of care, required a pacemaker or the patient expired. The bottom of the form has a space for completion time of the RRT and signature spaces for the Team Members in attendance along with the discipline.

Review on January 15, 2021, of the facility's "Notification of Family for Significant Change in Patient Condition" policy, last approved January 30, 2019, revealed "Policy: A significant change in a patient's condition will be communicated to the patients [sic] emergency contact. While it is preferred that the physician notify family of the patient's change in condition, the nurse or social services may contact the family to facilitate timely communication. The person who initiates the call, or their designee, should document the notification in patient's record. Procedure: 1. Event in which family members should be notified include, but are not limited to: Transfer to a higher level of care. A significant event resulting in a change in condition which does not necessitate transfer to a higher level of care, such as RRT. Unplanned surgery or procedure. Full arrest/Code Blue. Death Falls Restraints"

1. Review of MR1 on January 15, 2021, revealed on January 9, 2021, at 6:45 PM, MR1 was found in the patient bathroom shower with the top sheet from the bed wrapped around the neck hanging from the bathroom door jamb. The shower chair was found at MR1's feet. MR1 hung for approximately five minutes and had loss of consciousness.

Review of MR1 on January 15, 2020, revealed nursing documentation dated January 9, 2021, at 6:45 AM indicating MR1 was hanging with a noose made from a sheet, tied intricately and tightly around the neck, and was anchored over the bathroom door. MR1 was lifted up to relieve body weight from the ligature; EMP7 loosened the sheet from the neck to maintain airway and breathing and MR1 appeared less cyanotic during this intervention. Code blue was then initiated, and the medical team responded. MR1 was transferred by medical team to the ED.

Interview with EMP1, EMP2 and EMP3 on January 15, 2021, at approximately 7:30 PM confirmed the nursing documentation dated January 9, 2021, at 6:45 AM indicating MR1 was hanging with a noose made from a sheet, tied intricately and tightly around the neck, and was anchored over the bathroom door; MR1 was lifted up to relieve body weight from the ligature; EMP7 loosened the sheet from the neck to maintain airway and breathing and MR1 appeared less cyanotic during this intervention; a code blue was then initiated, and the Medical team responded with MR1 being transferred by medical team to the ED.

A request was made of EMP1, EMP2 and EMP3 for the Code Blue documentation.

Interview with EMP1 on January 15, 2021, at approximately 7:15 PM revealed there was no Code Blue sheet for MR1 in this patient's medical record, in the ED or in the Medical Records Department.

Phone interview with EMP6 on January 15, 2021, revealed MR1's Code Blue was changed to an RRT.

A request was made of EMP1 and EMP6 for the RRT documentation.

Interview with EMP1 and EMP3 on January 15, 2021, at approximately 7:30 PM revealed there was no documentation in MR1 regarding who made the determination to change MR1's code to an RRT.

Review on January 15, 2021, of the RRT documentation provided by EMP6 revealed an unlined piece of paper folded in half with hand written in red ink indicating the date and time; the patient's name; medical record number; room number and that this was an attempted suicide and taken to the ED.

Interview with EMP1 on January 15, 2021, at approximately 7:30 PM confirmed the unlined piece of paper folded in half with hand written in red ink indicating the date and time; the patient's name; medical record number; room number and that this was an attempted suicide and taken to the ED. EMP1 revealed the documentation on the unlined piece of paper is not considered appropriate documentation of an RRT and there was no Rapid Response Team (RRT) Documentation Form in MR1, in the ED or in the Medical Record Department.

There was no documentation in MR1 indicating what type of immediate emergent care this patient required when initially found hanging by staff.

2. Review of MR1 on January 15, 2021, revealed no documentation in MR1 indicating facility staff notified MR1's family regarding this patient's suicide attempt; loss of consciousness; Code Blue call or that MR1 was transferred to the ED for treatment.

Phone interview with EMP1 January 20, 2021, at approximately 10:45 AM confirmed there was no documentation on MR1 indicating facility staff notified MR1's family regarding this patient's suicide attempt; loss of consciousness; Code Blue call or that MR1 was transferred to the ED.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services