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Based on interview, record review and policy review, the hospital failed to ensure the safety of all behavior health patients when they failed to provide a contraband free and psychiatric (relating to mental illness) safe patient environment for one discharged patient (Patient #5) of one patient reviewed. (A-0144) The hospital also failed to ensure that restraint orders were renewed in a timely manner for three current patients (#1, #45, and #48) out of six records reviewed. (A-0168)

These failures had the potential to place all patients admitted to the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation (CoP): Patient's Rights. The hospital census was 230.

Based on interview, record review and policy review, the hospital failed to ensure the safety of all behavior health patients when they failed to provide a contraband free and psychiatric (relating to mental illness) safe patient environment for one patient (Patient #5) that was located in a monitored, psychiatric safe ED room. They failed to ensure that staff monitored the patient at all times; and there were no keys left in a tele-psych cart when it was taken in the patient's room.

Review of the hospital's undated policy titled, "Care of the Suicidal/Homicidal/Unsafe Patient", showed patients who screen with a high suicide risk will trigger immediate notification for the physician and/or a behavioral health consult. The patient will be placed under direct observation and staff will initiate the "NKCH (North Kansas City Hospital) suicidal, homicidal, and unsafe patient care guidelines".

Review of the hospital's undated document titled, "NKCH Suicidal, Homicidal, and Unsafe Patient Care Guidelines," directed staff to:
- Prepare the ED room for appropriate patient safety by removing items which could cause danger to the patient or others.
- Assign the patient to an inpatient room close to the nurse's station and away from stairs and elevators.
- Maintain constant visual contact of the patient, observing them for any potentially harmful behaviors and to never leave them alone.
- Monitor items coming in/out of the room for any dangerous items.

Although requested the hospital was unable to provide video recordings of ED room 13, room 16, the nurse's station or the hallway.

Review of Patient #5's medical record dated 07/08/24 through 07/09/24 showed:
- She was a 38-year-old female, who presented to the ED having suicidal ideations (SI, thoughts of causing one's own death) and had self-harmed by cutting her wrist.
- Her recent history included multiple attempts at cutting her wrist to end her life. She required surgical intervention for a recent attempt. She reported intrusive thoughts, where she "feels like a robot" and would attempt to cut her wrist. She did not have persistent intent or a plan but would have significant periods of intrusive thoughts. Prior to her ED visit, she had thought about cutting her wrist with a knife. Her wife intervened. There was a small amount of bleeding on her wrist where she had been picking at the surgical wound.
- Staff CC, Physician, documented that she had a "mild controlled wound to the left wrist, no evidence of arterial bleed or injury to her radial/ulnar artery." A small amount of skin glue was placed on the wound. A behavioral health consult was ordered.
- At 12:50 AM, a Nurse's Note showed that Patient #5 had a one-centimeter (cm) laceration (a deep cut or tear in skin) to the left wrist. The patient reported the laceration was old but that she had been picking it open. The bleeding was controlled. The patient reported having no plan other than cutting her wrist and had no SI at that time.
- At 2:44 AM, a Tele-psychiatry note showed the patient had a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock).She presented to the ED for intermittent intrusive thoughts to kill herself by cutting her wrists for the past two weeks. One episode required surgical intervention. On the evening of 07/08/24, the patient tried to cut her wrist with a knife, but her wife intervened. She had been picking at a previous wound. She presented to the hospital because she broke open a razor, removed the blade, and attempted to re-cut her wrist. While in the ED she admitted to trying to reopen the glued wound with her thumb.
- At 4:30 AM, a dressing was applied to the patient's left wrist.
- At 7:00 AM, the patient's family was at the bedside.
- At 7:43 AM, Staff FF, RN, documented she was informed that the patient had taken the tele-psych cart keys off the cart during the tele-psych assessment around 2:40 AM. The patient gave the keys to her sister, who then informed Staff C, MHT. When asked why she had taken them, the patient stated, "they were shiny and when I see shiny things, I take them to cut myself." The patient stated, "shiny things" make her impulsive and caused intrusive thoughts to self-harm. She denied any specific trigger. Her left wrist and dressing were assessed, they remained clean, dry, and intact. Staff FF completed a sweep of the patient's room to locate any other objects that the patient could use to harm herself with. She ensured all her personal belongings were locked in a cabinet within the patient's room.
- At 1:08 PM, the patient was admitted to the hospital due to lack of psychiatric bed availability.
- On 07/09/24 at 3:00 PM, the patient was transferred to an inpatient psychiatric hospital.

During an interview on 08/07/24 at 12:50 PM, Staff QQ, BHA, stated that BHAs were not required to stay in the room with patient's during the tele-psych consultations. She took the cart into the patient's room but did not notice if the cart had any keys on it. She stated, "she did not look down," and "only checked that the screen and the volume were working."

During an interview on 08/07/24 at 11:00 AM, Staff NN, MHT, stated that she was responsible for watching the patient during the night shift on 07/08/24. During her shift, the patient's sister reported to her that the patient had reopened the wound on her wrist. She immediately reported that to the patient's nurse. Staff NN was not aware of the patient having any keys until her supervisor reached out to her the next day. The patient's sister never mentioned any keys to her, and she did not see the patient with any keys.

During an interview on 08/07/24 at 7:30 AM, Staff EE, RN, stated the physician ordered the patient's wrist wound to be glued and have a dressing placed. There was not a lot of blood, and she did not remember how the wound had opened. The patient did not have any keys.

During an interview on 08/06/24 at 1:00 PM, Staff CC, Physician, stated that Patient #5 came to the ED due to SI and that prior to her arrival she had been picking at an old wound on her left wrist. While in the ED, the patient continued to pick at her wrist, so it was covered with glue to provide a protective barrier and to maintain integrity of the skin. It was not gapping open, it was a small opening, there was not a lot of blood. To his knowledge the patient did not harm herself with anything she obtained from the hospital.

During an interview on 08/07/24 at 1:02 PM, Staff C, MHT, stated that she was responsible for supervising the patient during the dayshift of 07/08/24. The patient's sister came up to her shortly after her shift started and gave her a key. She asked the patient's sister where she got it from, and she said the patient gave it to her. She said the patient got it from the tele-psych cart that was left in the room and the that she had been hiding it. She went to the patient's room, removed the cart and took the key to a BHA. The key was bent but she did not remember there being any blood on the key.

During an interview on 08/07/24 at 9:00 AM, Staff FF, RN, stated that she took over Patient #5's care at 7:00 AM, on 07/08/24, and the patient was asleep. Shortly after, it was reported to her, by Staff C, that the patient's sister brought her a key and told her that the patient had been hiding it. The patient's sister said a tele-psych cart was brought in for a consult in the middle of the night, there were keys on the cart, and no one was watching the patient, so she took the keys and started picking at her scabs under the blankets before her wound was cleaned and bandaged. The patient's sister said the patient got bored so she put the keys underneath her body and went to sleep. Staff FF immediately went to assess the patient. There was a very minimal amount of dried blood on the patient's blanket. When she checked the patient's wound, the wound was bandaged, and the bandage was dry and intact. Nothing had been disturbed on the bandage. She never saw any evidence of the wound being picked at.

During an interview on 08/07/24 at 12:30 PM, Staff RR, Charge RN, stated that the patient's family member told Staff C, MHT, that the patient had attempted to re-open her wound with a pair of keys that she found in the room. After being notified of the incident she assessed the patient's wrist. It had a bandage wrap on it, and she removed the wrap to assess the wound. The wound had a glue dressing that was still intact, and was not bleeding. The patient's bed sheets had a smear mark of dried blood that was approximately five inches long by 1/8 inch wide. She completed an event report, and the department directors were notified.

A-0168
Based on interview, record review and policy review the hospital failed to ensure the physician renewal orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were written daily for three current patients (#1, #45 and #48) of six restraint patients reviewed. These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's non-dated policy, "Restraint Usage," showed an order for Non-Violent/ Non-Self-Destructive restraints must be renewed daily for each instance a patient's condition required restraints.

Review of Patient #1's medical record showed:
- On 07/28/24 at 4:30 PM, while in the neuro-trauma intensive care unit (NTICU, an intensive care unit devoted to the care of patient with immediately life-threatening nervous system problems and traumatic injuries) an initial restraint order was placed for non-violent soft bilateral upper extremity (BUE) restraints.
- On 07/30/24, there were no restraint orders.
- Nursing documentation showed that Patient #1 was in restraints on 07/30/24, with no order for restraints.
- On 07/31/24 at 7:00 PM, a renewal order was placed for non-violent BUE restraints.

Review of Patient #45's medical record showed:
- 07/24/24 at 7:32 AM, while in the cardiac intensive care unit (CICU, an intensive care unit devoted to the care of patients with immediately life-threating cardiac problems) an initial restraint order was placed for non-violent soft BUE restraints.
- On 07/27/24, there were no restraint orders.
- Nursing documentation showed that Patient #45 was in restraints on 07/27/24, with no order for restraints.
- On 07/28/24 at 6:15 PM, a renewal order for non-violent BUE restraints, was placed.

Review of Patient #48's medical record showed:
- On 07/24/24 at 11:16 PM, while in the cardiovascular intensive care unit (CVICU, an intensive care unit devoted to the care of patient's recovery from heart surgery) an initial order was placed for non-violent BUE restraints.
- On 07/25/24, there were no restraint orders.
- Nursing documentation showed that Patient #48 was in restraints on 07/25/24, with no order for restraints.
- On 07/26/24 at 7:41 AM, a renewal order for non-violent BUE restraints, was placed.
- On 07/26/24 at 11:00 PM, a second renewal order for non-violent BUE restraints was placed.
- On 07/27/24, there were no restraint orders.
- Nursing documentation showed Patient #48 was in restraints on 07/27/24, with no order for restraints.
- On 07/28/24 at 7:00 PM, a renewal order for non-violent BUE restraints, was placed.
- On 08/05/24, a renewal order for non-violent restraints, was not placed.
- Nursing documentation showed Patient #48 was in restraints on 08/05/24, with no order for restraints.
- On 08/06/24 at 11:00 PM, a renewal order for non-violent BUE restraints, was placed.

On 08/05/24 at 3:00 PM, Staff F, Charge Nurse, stated that renewal restraint orders would be renewed every calendar day. Nurses receive a reminder to contact the physician so a renewal order can be placed. She confirmed that on 07/30/24, Patient #1 did not have a daily non-violent restraint order placed.

During an interview on 08/07/24 at 3:15 PM, Staff O, Senior Nursing Director, stated that an order for non-violent restraints must be renewed each calendar day. It was the responsibility of the physician to renew restraint orders every calendar day. Nursing would receive a task notification to notify the physician when restraint orders need renewed.