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Based on observation, review of medical records, and staff interviews, the facility failed to ensure that 5 of 13 patients (Patients #11, #12, #13, #14, and #17) on Unit One (a psychiatric intensive care unit) received psychiatric care in a safe setting as evidenced by:

A. Patients #12 and #13 were assigned to room 102.

1) The ceiling light troffer in that room had a half inch gap between the metal lip of the troffer and the ceiling, creating anchor points that could be used to attach material for the purpose of hanging or strangulation. In addition, the compromised light fixture had the potential of exposing patients to electrical wiring.

2) A shower chair had been left in the bathroom. The shower chair could have provided additional height to reach the ceiling light troffer. The shower chair itself created anchor points that could be used to attach material for the purpose of hanging or strangulation.

3) The compromised light fixture and the shower chair were not documented as patient safety concerns on the Environmental Rounds form conducted on 10/1/2020.

B. The door between two day areas on Unit 1 had been locked, thus dividing the unit into two patient care areas and resulting in patients #11, #14, and #17 being in their beds on a locked wing of Unit 1 with no staff member physically present in that area.


Findings included:

The following observations were made during a tour of Unit One on 10/1/2020 from 10:45am to 11:15am:
The two surveyors were escorted to the unit by Staff B (Quality Director) and Staff C (Chief Nursing Officer - CNO). The nurse's station faced two day areas. The day areas were divided in half by a wall. Staff moved between the day areas through a door. That door was closed and locked. Off each day area was a hallway with patient bedrooms. Patients were observed on each hallway. A whiteboard in the nurse's station showed that the seven (7) male patients were assigned to one hallway and the six (6) female patients to the other hallway. Staff F (RN) was behind the nurse's station. Staff I (MHT) was observed entering the day area onto the female side of the unit from the male side. She unlocked and relocked the door, made rounds on the female side, and returned to the male side, again unlocking and relocking the door. Staff H (MHT) was observed in an outside smoking area monitoring both male and female patients.

In an interview with Staff F (RN) on 10/1/2020 at 10:45am, she identified herself as the charge nurse. When quizzed about the door being locked between the two patient care areas, she stated it was locked because Patient #17 was hypersexual and needed to be kept from the male patients, adding, "The door is usually not locked." She went on to say that she had thirteen (13) patients and was staffed with a medication nurse (Staff G) and two MHTs (Staff H and Staff I). During this conversation with Staff F, Staff G (RN / medication nurse) emerged from the medication room. It was noted that no staff member was stationed on the female side of the unit and the door between the two day areas was locked. Staff F (Charge RN) stated she had two MHTs - one MHT was making the 15-minute observation rounds and the other MHT was outside with the patients who were taking a smoke break. Staff G stated she could watch the female hallway. The locked door was opened and remained open and unlocked throughout the remainder of the tour.

The surveyors were escorted down the female hallway by Staff B (Quality Director) and Staff C (CNO). Female patients were observed in bed in rooms 101, 103, and 104. The doors to the bedrooms were slightly ajar.

Record review of the Observation Rounds / Precaution forms dated 10/1/2020 showed that Staff I (MHT) conducted the 10:45am and 11:00am rounds on the following female patients:
Patient #11 was asleep in room 101. She was on elopement precautions.
Patient #14 was awake in room 103. She was on aggression / homicidal precautions and elopement precautions.
Patient #17 was asleep in room 104 at 10:45am and awake in room 104 at 11:00am. She was on sexually acting out - aggressor precautions, aggression / homicidal precautions, and elopement precautions.

Further observation in patient room 102 revealed a problem with the ceiling light fixture. Light was furnished by florescent lamp(s) housed in a ceiling light troffer (approximately 1' X 4'). On one end, it had a half inch gap between the metal lip of the troffer and the ceiling. The surveyor was able to reach up and touch the lip of the troffer. A slight tug on the troffer increased the gap to about an inch. No further attempt was made to pull on the fixture due to concerns that it might dislodge further from the ceiling.

In interviews with Staff B (Quality Director) and Staff C (CNO), they stated the light fixture created a safety issue, noting that:

1) If the troffer was secured to the ceiling in such a manner that it could not be pulled down, it created a tie off point and could be used for hanging.

2) If it was not adequately secured to the ceiling and could be pulled down, electrical wires could be accessed.

Continued observation in room 102 revealed a shower chair in the bathroom. The shower chair was constructed of metal tubes and durable plastic. Two metal tubes supported the plastic back rest. The four legs were also constructed of metal tubes and had non-slip feet. Additional support bars crisscrossed about 6 inches beneath the plastic seat, providing additional strength and durability to the legs. The height of the seat was adjustable.

During continued interviews with Staff B (Quality Director) and Staff C (CNO), they stated that standing on the shower chair could place a patient closer to the light fixture, creating a safety issue. Staff B identified the two (2) patients assigned to room 102 as Patient #12 and Patient #13. She further stated that Patient #12 was in a wheelchair, thus the need for a shower chair.

Final observation of the light troffers in bedrooms 101, 103, 105, 106, 107, and 108 on Unit 1 were flush to the ceiling with no gaps between the lip and the troffer and the ceiling. On Unit 8, the light troffers in bedrooms 803 and 804 were flush to the ceiling with no gaps between the lip and the troffer and the ceiling.

Record review of the Psychiatric Evaluation for Patient #12 conducted by Staff Y (MD), dated 9/30/2020 at 6:59pm, showed a 29yo female with bipolar disorder and multiple injuries secondary to physical trauma from falls and assaults. She stated she slammed her ankle into a door and had to use a walker. Sometimes a wheelchair was used to ambulate. She stated she had fleeting suicidal ideation.

Review of the Psychiatric Evaluation for Patient #13 conducted by Staff Z (MD), dated 9/23/2020 at 9:30am, showed a 43yo female admitted on an emergency detention warrant with thoughts of killing others and herself. She was suicidal with a plan, intent, and means. She was actively hallucinating.

Record review of the Environmental Rounds form conducted on 10/1/2020, 7:00am - 7:00pm, by Staff I (MHT) and reviewed by Staff F (Charge RN) did not contain any documentation of the compromised light fixture and the shower chair as patient safety concerns. It was further noted that the form did not prompt the staff member to assess for tie off points or fixtures (such as ceiling light fixtures) that needed to be repaired.

In an email from Staff B (Quality Director) dated 10/2/2014 at 4:11pm she wrote, "Environmental rounds are conducted on all units, once during each 12-hour shift by either a MHT or a nurse depending on the staffing that day on the unit. There is a form with two columns to be completed that reflects the day shift round and the evening shift round. The completed sheets are turned in to the Nurse Supervisor at the end of the night shift and Plant Operations is notified of any maintenance issues. Then they are sent up to the Chief Nursing Officer who uses them for ... PI [Performance Improvement] report and compliance monitoring ..."

Review of the literature.
Record review of The Joint Commission Perspectives, November 2017, Volume 37, Number 11: "Special Report: Suicide prevention in Health Care Settings - Recommendations Regarding Environmental Hazards for Providers and Surveyors" showed: "Recommendations for Inpatient Psychiatric Units ... must be ligature-resistant in the following areas: patient rooms, patient bathrooms ..."

Record review of The Joint Commission documents on patient safety/suicide revealed: "The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging)."
https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/r3_18_suicide_prevention_hap_bhc_5_6_19_rev5.pdf?db=web&hash=887186D9530F7BB8E30C28FE352B5B8C

Based on observation, review of medical records, and staff interviews, the facility failed to ensure that Staff F (RN) took into consideration the complexity of patient's care needs, environmental safety concerns, and physical distribution of patients for 3 of 13 patients (Patients #11, #14, and #17) on Unit One (a psychiatric intensive care unit) as evidenced by:

A. The door between the two day areas on Unit 1 had been locked, thus dividing the unit into two patient care areas. This resulted in patients #11, #14, and #17 being in their beds on a locked wing of Unit 1 with no staff member physically present in that area.

B. Conflicting staff assignments with two MHTs (Staff H and Staff I) being assigned 15 minute rounds and courtyard duty concurrently.


Findings included:

The following observations were made during a tour of Unit One on 10/1/2020 from 10:45am to 11:15am:
The two surveyors were escorted to the unit by Staff B (Quality Director) and Staff C (Chief Nursing Officer - CNO). The nurse's station faced two day areas. The day areas were divided in half by a wall. Staff moved between the day areas through a door. That door was closed and locked. Off each day area was a hallway with patient bedrooms. Patients were observed on each hallway. A whiteboard in the nurse's station showed that the seven (7) male patients were assigned to one hallway and the six (6) female patients to the other hallway. Staff F (RN) was behind the nurse's station. Staff I (MHT) was observed entering the day area onto the female side of the unit from the male side. She unlocked and relocked the door, made rounds on the female side, and returned to the male side, again unlocking and relocking the door. Staff H (MHT) was observed in an outside smoking area monitoring both male and female patients.

In an interview with Staff F (RN) on 10/1/2020 at 10:45am, she identified herself as the charge nurse. When quizzed about the door being locked between the two patient care areas, she stated it was locked because Patient #17 was hypersexual and needed to be kept from the male patients, adding, "The door is usually not locked." She went on to say that she had thirteen (13) patients and was staffed with a medication nurse (Staff G) and two MHTs (Staff H and Staff I). During this conversation with Staff F, Staff G (RN / medication nurse) emerged from the medication room. It was noted that no staff member was stationed on the female side of the unit and the door between the two day areas was locked. Staff F (Charge RN) stated she had two MHTs - one MHT was making the 15-minute observation rounds and the other MHT was outside with the patients who were taking a smoke break, adding that they "trade off" [assignments]. Staff G stated she could watch the female hallway. The locked door was opened and remained open and unlocked throughout the remainder of the tour.

The surveyors were escorted down the female hallway by Staff B (Quality Director) and Staff C (CNO). Female patients were observed in bed in rooms 101, 103, and 104. The doors to the bedrooms were slightly ajar.

Record review of the Observation Rounds / Precaution forms dated 10/1/2020 showed that Staff I (MHT) conducted the 10:45am and 11:00am rounds on the following female patients:
· Patient #11 was asleep in room 101. She was on elopement precautions.
· Patient #14 was awake in room 103. She was on aggression / homicidal precautions and elopement precautions.
· Patient #17 was asleep in room 104 at 10:45am and awake in room 104 at 11:00am. She was on sexually acting out - aggressor precautions, aggression / homicidal precautions, and elopement precautions.

Record review of Staffing [assignment sheet] form dated 10/1/2020 showed four staff members on duty. These included: Staff F (Charge RN), Staff G (RN Medication Nurse), Staff H (MHT) and Staff I (MHT). Thirteen patients were identified on the assignment sheet. This count included patients #11, #14, and #17 (those patients in bed on the unit). The assignment sheet identified Staff H (MHT) as responsible for the 15 minute rounds from 9:30am through 12:30pm. [Note: As documented above, Staff I (MHT) conducted the 15 minute rounds - not Staff H (MHT).] Further review of the assignment sheet showed that Staff H and Staff I were both assigned courtyard duty concurrently.

Based on record review, interview, and observation, the facility failed to ensure that the Initial Psychiatric Evaluation on 1 of 2 patients (Patient #13) contained a record of mental status that described the content of suicidal ideation.


Findings included:

Record review of the Initial Psychiatric Evaluation by Staff Z (MD), dated 9/23/2020 at 9:30am showed a 43yo female admitted on an Emergency Detention Warrant stating, "My boyfriend sold my children on line. I will kill him and myself." She had been showing increased aggression towards her family and the police. She reported people were out to hurt her and she would "hurt them first." She was actively hallucinating, talking to people not there. Staff Z (MD) documented "Thought Content / Cognition," an element of the mental status examination, by noting suicidal ideation. He did not designate active or passive suicidal ideation as prompted by the form. He checked the following items:
1) Plan
2) Intent
3) Means
The form has a line beside each item for the physician to describe the plan, determine the intent, and outline the means. Staff Z (MD) did not document a thorough assessment of these items.
Justification for admission:
1) Hallucination, delusions, agitation, anxiety, depression, and/or mood instability resulting in significant loss of functioning.
2) Danger to self, others, or property with need for controlled environment.
Psychiatric Diagnosis: Schizoaffective disorder, bipolar type; cannabis use disorder, severe

In a phone interview with Staff D (Medical Director) on 10/9/2020 at 11:00am, he discussed the Initial Psychiatric Evaluation on Patient #13 conducted by Staff Z (MD) on 9/23/2020 at 9:30am. He stated that if a patient is suicidal with a plan, intent, and means, that information should be documented within the Psychiatric Evaluation. He acknowledged problems with this issue in the past, adding he would discuss this with the physicians in the next Medical Executive Committee meeting.

Record review of Medical Staff Rules and Regulations, approved September 2020 showed:
"2.8.1
The Psychiatric Evaluation should include ... Determination of the degree of danger patient presents to self or others."