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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:


1. The Hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients (See A-144).

Based on document review and interview, it was determined for 1 of 2 (Pt #5) Emergency Department (ED) patients reviewed for 1:1 continuous monitoring, the Hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients.

Findings include:

1. On 12/01/23 at approximately 11:00 AM the policy titled "Suicide Prevention (approved 01/22/23)" was reviewed. The policy stated, "... IV. Procedure/Interventions: A. Non-Behavioral Health Settings (Acute Care, Critical Care, Emergency Department) 1. Screening:... 2. Patients who present to an ED or OB triage for evaluation or treatment of a behavioral health condition will be screened for suicidal ideation using age-appropriate C-SSRS (Columbia Suicide Severity Risk Scoring) at the facility.... 7. Emergency Department Considerations: a) Follow risk-based protocols.. if a patient requires monitoring they should not be left unattended at any time during their ED evaluation.... c) if a safer room is not available, the room will be made as ligature resistant as possible.... Appendix A: Behavioral Health Risk Mitigation Plan C-SSRS/Safe-T Risk Mitigation Plan Acute Care and ED: Patient Monitoring.... High Risk: 1:1 Continuous monitoring with Patient Safety Companion, patient is never left alone... the frequent observation form is completed approximately every 15 minutes at a minimum of 4 times per hour.

2. On 12/01/23 at approximately 1:00 PM, Pt #5's record was reviewed. Pt #5 was admitted to the ED on 11/29/23 at 4:02 PM with chief complaints of Suicidal Ideation and Homicidal Ideations. Triage note at 4:18 PM stated, "Pt states (Pt #5) was just discharge for SI and HI from here. Pt says (Pt #5) is still having HI, SI, denies drugs or alcohol usage. Pt has not been taking his medications ..." the Columbia Suicide Screening was completed at 4:21 PM and stated, "Columbia Caluclated Risk Level: High..." A note placed by an ED Physician Assistant at 7:59 PM stated, "Informed Charge RN that the patient should be roomed as (Pt #5) has been in the waiting room for almost four hours and is suicidal and homicidal. (Charge RN) was unaware that the patient had SI and HI and will bring (Pt #5) back." Pt #5 was then placed in ED Behavioral Health Room #3 at 8:46 PM. 1:1 sitter documentation started at 8:52 PM. The record lacked any monitoring between 4:21 PM and 8:46 PM.

3. On 12/01/23 during the record review, an interview was conducted with Nursing Professional Development RN (E #6). E #6 stated, "Looks like the pt was sitting in the waiting room for almost 4 hours. I do not see any documentation of 1:1 observation and there should have been."