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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 a one to one sitter provided continuous observation for a suicidal patient that resulted in the patient lacerating themself.

A discussion took place with the survey team and the facility's administrative staff (EMP1 and EMP2) regarding the survey team's concerns related to Patient's Rights on July 23, 2020 at approximately 2:30 PM.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure a complainant was informed of an update on an investigation, the facility failed to notify the complainant that the response time may be greater than 14 days, and the facility failed to provide a final resolution for one of one complaint reviewed.

Findings include:

Review on July 24, 2020, of facility policy, "Patient Complaint-Grievance Process Policy," revised December 7, 2019, revealed, "Purpose: To provide a systematic approach to address complaints. ...Definitions: If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, it is postponed for later resolution, is referred to other staff for later resolution, then the complaint is a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf or closed as further provided in this policy. ...Policy: It is the responsibility of all staff to serve as patient advocates and to respond to the concerns expressed by the patient and their families. ...It is the policy to acknowledge, investigate and if possible resolve problems revealed by complaints from clients, families, and physicians within seven (7) days of notification of the problem. Written complaints will be logged within 48 hrs. and acknowledged within 7 days of receipt and fully addressed within 14 days. Some investigation take longer than 14 days and the complainant will be informed of an update on the investigation and notification that the time may be greater than 14 days. A letter or phone call will acknowledge receipt of complaint, provide a 14 day update and ultimately provide the final resolution ...."

Review on July 24, 2020, of the facility complaint log revealed the complainant filed a complaint with the facility on January 29, 2020. The facility sent the complainant a written acknowledgment letter on January 30, 2020. A letter was sent to the complainant on February 29, 2020, stating the course of hospitalization was still currently under review. This review revealed no documentation the complainant was provided with a final resolution.

Interview on July 24, 2020, with EMP6 confirmed an acknowledgement letter was sent to the complainant on January 30, 2020. EMP6 confirmed the facility sent the complainant a second letter on February 29, 2020 stating the course of hospitalization was still currently under review. EMP6 revealed the complainant was not sent a letter regarding an update on the investigation and that it may take greater than 14 days. EMP6 revealed the complainant was not provided with the final resolution.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to notify a patient's family of the patient's transfer from the telemetry unit to the Intensive Care Unit for one of one medical record reviewed (MR2).

Findings include:

Review of the facility's "Transfer Intra-facility and Inter-facility Policy," last revised February 27, 2019, revealed "... III. Guidelines A. Intra-facility Transfers: ... 3. The transferring unit will ensure all consulting practitioners and family / POA are notified of the patient transfer ..."

Review of MR2 on July 23, 2020, revealed the facility transferred this patient from the telemetry unit to the Intensive Care Unit (ICU) on December 30, 2019, due to a change in medical condition.

Review of MR2 on July 23, 2020, revealed no documentation MR2's family was notified of the transfer from the telemetry unit to the ICU on December 30, 2019.

Interview with EMP3 on July 23, 2020, at approximately 12:45 PM confirmed MR2's family was not notified of MR2's transfer from the telemetry unit to the ICU on December 30, 2019.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a one to one sitter provided continuous observation for a suicidal patient, that resulted in the patient lacerating themself for one of one medical record reviewed (MR1).

Findings include:

Review on July 23, 2020, of the facility "Notice Of Patient Rights and Responsibilities," revised September 2018, revealed, "You have the right to: ... An environment that is safe, preserves dignity ..."

Review on July 23, 2020, of the facility's "Suicide Risk Assessment and Interventions: Columbia Protocol In Non-Behavioral Health Setting Policy," last revised December 20, 2019, revealed "I. Policy All adolescent and adult patients (ages equal or greater [sic] 11 years of age who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). ... Based on the severity and immediacy of the suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. ... III. Definitions ... B. One to One (1:1) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times. ..."

Review on July 23, 2020, of the facility's "Trained Observers Policy," effective date October 22, 2019, revealed "I. Purpose A. To provide guidelines for the use of a trained observer. B. To promote safety for patients at risk for suicide and patients at risk of injuring themselves or others. II. Scope A. Trained Observer - This role is to provide continual observation for the patient identified as at risk for suicide, or at risk for injury... P. The trained observer must sit in the patient room with an unobstructed view of the patient. ... Q. The trained observer accompanies the patient for any clinical tests or procedures off the unit. the trained observer must remain within arm's length distance of the patient unless otherwise directed .... The observer should never accompany the patient alone. ... 2. Patients are not permitted to leave the unit or go outside to smoke, get some fresh air, etc. ..."

Review on July 23,2020, of MR1 revealed this patient was admitted to the Emergency Department (ED) on March 7, 2020, at 9:56 AM under a 302 (Involuntary psychiatric commitment) for a psychiatric evaluation after taking extra medication for sleep. At 10:14 AM, MR1 revealed taking the extra medication was to harm self; had suicidal thoughts and had a history of cutting self on the arms. The facility completed a C-SSRS and determined MR1's level of suicide risk as high and initiated 1:1 Observation for this patient's safety.

Interview with EMP1 and EMP2 on July 23, 2020, at approximately 1:45 PM confirmed MR1 was admitted to the ED on March 7, 2020, under a 302 for a psychiatric evaluation after taking extra medication for sleep; at 10:14 AM, MR1 revealed taking the extra medication was to harm self; had suicidal thoughts and had a history of cutting self on the arms and the facility completed a C-SSRS and determined MR1's level of suicide risk as high and initiated 1:1 Observation for this patient's safety.

Review on July 23, 2020, of MR1's nursing documentation dated March 7, 2020, at 5:00 PM revealed MR1 was taken to a bathroom in the ED where this patient was unsupervised; MR1 found a wood tongue depressor while in the bathroom; broke the wood tongue depressor into pieces; returned to the ED room; sat on the floor facing away from the 1:1 sitter; and began to stab self with the wood tongue depressor pieces resulting in a one centimeter laceration to the left cubital space requiring two sutures.

Interview with EMP1 and EMP2 on July 23, 2020, at approximately 1:50 PM confirmed MR1 was taken to a bathroom in the ED where this patient was unsupervised; MR1 found a wood tongue depressor while in the bathroom; broke the wood tongue depressor into pieces; returned to the ED room; sat on the floor facing away from the 1:1 sitter; and began to stab self with the wood tongue depressor pieces resulting in a one centimeter laceration to the left cubital space requiring two sutures. EMP1 and EMP2 revealed MR1 used the third ED bathroom and that this patient found the wood tongue depressor in the garbage can in this bathroom.

Observation on July 23, 2020, of the ED revealed three bathrooms for patient use. The first bathroom is located near the nurse's station and contained a metal hook secured to the wall with a nail, a rigid garbage can containing a plastic garbage bag liner, two open metal handicap bars attached to the wall near the commode; a louvered vent directly above the commode and a cloth call bell cord; the second bathroom was located near patient rooms 19 and 20 and contained a metal hook secured to the wall with a nail, a rigid garbage can containing a plastic garbage bag liner, two open metal handicap bars attached to the wall near the commode; a louvered vent directly above the commode and a cloth call bell cord; and the third bathroom was also located near patient rooms 19 and 20 and contained a metal hook secured to the wall with a nail, a rigid garbage can containing a plastic garbage bag liner, two open metal handicap bars attached to the wall near the commode; a louvered vent directly above the commode; a cloth call bell cord and patient care supplies which included urine collection containers and specimen cups and boxes of various sizes of gloves.

Interview with EMP1 and EMP2 on July 23, 2020, at approximately 6:00 PM confirmed the three bathrooms in the ED for patient use and the contents of each of these bathrooms as described above.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure sufficient medical information to ensure continuity of patient care was transferred with a patient when transferred to another acute care facility for one of one medical record reviewed (MR2).

Findings include:

A request was made of EMP1 and EMP2 on July 24, 2020, for a facility policy / procedure / guideline facility staff would utilize to complete the Commonwealth Health Regional Hospital of Scranton Transfer Form SCRN1699A. None was provided.

Review on July 24, 2020, of the facility's "Transfer Intra-facility and Inter-facility Policy," last revised February 27, 2019, revealed "... III. Guidelines ... B. Inter-facility (i.e. Other Acute Facility, Higher Level Facility): ... 6. Complete "Patient Transfer Form" - Must be completed on all transfers. Section A. #'s 1, 2, & 3 will be completed by nurse transferring patient. Section B, will be completed by patient or patient's legal guardian. Section C, will be completed by physician ordering patient transfer. The white (original) copy of the completed form will be placed on the patient chart and send the copy (yellow) with the patient's medical records. ..."

Review on July 24, 2020, of the facility's "Commonwealth Health Regional Hospital of Scranton Transfer Form SCRN1699A" no review date, revealed an area at the top left of the form for facility staff to document the patient's Code Status; Advanced Directives; Date and Time of Transfer; and if the patient received the Pneumococcal and Flu vaccine and the date received.

Review on July 24, 2020, of MR2's Commonwealth Health Regional Hospital of Scranton Transfer Form revealed no documentation the facility completed the required information of this patient's Code Status; Advanced Directives; Date and Time of Transfer; and if this patient received the Pneumococcal and Flu vaccine and the date received.

Interview with EMP1 on July 24, 2020, at approximately 11:35 AM confirmed there was no documentation the facility completed the required information of this patient's Code Status; Advanced Directives; Date and Time of Transfer; and if this patient received the Pneumococcal and Flu vaccine and the date received.

Review on July 24, 2020, of the facility's "Commonwealth Health Regional Hospital of Scranton Transfer Form SCRN1699A" no review date, revealed an area in the middle of the form for facility staff to document the name of the family member notified and relationship to the patient; the name of the receiving facility; the name of the receiving physician; the mode of transportation ambulance or helicopter, the name ambulance or helicopter; the utilization of ALS (Advanced Life Support) or BLS (Basic Life Support); if the patient was notified of the transfer and the name of the physician informing the patient; facility personnel accompanying the patient; if radio contact is to be maintained with the transferring or receiving hospital; medical orders for during transfer; what information from the medical record will be sent with the patient and the signature of the physician.

Review on July 24, 2020, of MR2's Commonwealth Health Regional Hospital of Scranton Transfer Form revealed no documentation the facility completed the required information on the facility's transfer form, which included the family member notified and relationship to the patient; the name of the receiving facility; the name of the receiving physician; the mode of transportation ambulance or helicopter, the name of ambulance or helicopter; the utilization of ALS or BLS; if the patient was notified of the transfer and the name of the physician informing the patient; facility personnel accompanying the patient; if radio contact was to be maintained with the transferring or receiving hospital; medical orders for during transfer; what information from the medical record will be sent with the patient and the signature of the physician.

Interview with EMP1 on July 24, 2020, at approximately 11:55 AM confirmed there was no documentation the facility completed the required information on the facility's transfer form, which included the family member notified and relationship to the patient; the name of the receiving facility; the name of the receiving physician; the mode of transportation ambulance or helicopter, the name ambulance or helicopter; the utilization of ALS or BLS; if the patient was notified of the transfer and the name of the physician informing the patient; facility personnel accompanying the patient; if radio contact was to be maintained with the transferring or receiving hospital; medical orders for during transfer; what information from the medical record will be sent with the patient and the signature of the physician.