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Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to implement interventions necessary to provide a safe setting for the care of three suicide-risk patients per facility policy (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On December 12, 2024 at 1:09 PM, an IJ was identified. On December 12, 2024 at 2:39 PM, the IJ template was presented to the administration and an acceptable removal plan was accepted on December 13, 2024 at 11:07 AM. On December 13, 2024, verification of the IJ removal plan was conducted and included the following: review of staff re-education, sign in-sheets, and staff interviews regarding the facility's process for placing patients on 1:1 observation. The IJ was lifted on December 13, 2024 at 12:12 PM.

Cross Reference:
482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on medical record review, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure the patient's rights to have their pain assessed, managed, and maintained in four of four medical records reviewed (Patient (P) 2, P4, P9, and P19).

Findings include:

Facility Policy titled, "Implementation of Patient Rights" (reviewed 12/2023), states, " ... PURPOSE: To ensure that: ... 5. Patients have their pain assessed as outlined in the pain management policy. ... PATIENT RIGHTS ... Pain Management. Activities are planned/coordinated to ensure pain is recognized/addressed appropriately in accordance with care/treatment/services including: Assessing for pain. Educating all relevant providers about assessing/managing pain. Educating patients/families about their roles in managing pain and potential limitations and side effects of pain treatments. ..."

Facility Policy titled, "Pain Management and Assessment" (revised 12/2022), states, " ...POLICY: All patients have the right to pain assessment and management as an important part of their care, therefore: 1. All patients will have an assessment of pain upon admission. ... PROCEDURE: A. Assessment of Patients ...1. Screen for the presence of pain at the time of admission by eliciting a pain response regarding the current presence of pain or pain experienced in the last few weeks.

On 12/11/24, a review of P2, P4, P9, and P19's medical record review, revealed the following:

On 11/11/24 at 11:49 AM, P2 arrived in the Emergency Department (ED) with complaints of chest pain.

On 11/11/24 at 11:53 AM, P2's vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

On 11/11/24 at 12:03 PM, P2 had an electrocardiogram (ECG) performed.

On 11/11/24 at 1:58 PM, P2's ED Disposition was set to "LWBS (left without being seen) after triage."

P2's medical record lacks documented evidence that a pain assessment was performed during P2's ED visit.


On 10/7/24 at 8:03 PM, P4 arrived in the ED with complaints of generalized chest pain to the right side of his/her neck that was getting gradually worse.

On 10/7/24 at 8:24 PM, P4's vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

On 10/7/24 at 8:45 PM, P4 was seen by an ED physician and orders were placed.

On 10/7/24 at 8:46 PM, the patient's first pain assessment was documented when P4 was given IV Toradol (a pain medication).

P4's medical record lacked documented evidence that a pain assessment was completed during triage.


On 11/1/24 at 12:25 AM, P9 arrived in the ED with complaints of knee pain.

On 11/1/24 at 12:28 AM, P9's vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure and oxygen saturation.

On 11/1/24 at 5:20 AM, P9's ED Disposition was set to "LWBS after triage."

On 12/12/24 at 12:23 PM, S4, confirmed the medical record lacked evidence of a pain assessment or re-assessment. When questioned if P5 should have been re-assessed during his/her wait, S4 stated, "yes."

P9's medical record lacked documented evidence that a pain assessment was performed during P9's ED visit.


On 10/1/24 at 6:29 PM, P19 arrived in the ED with complaints of chest and abdominal pain.

On 10/1/24 at 6:32 PM, P19's vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

On 10/1/24 at 7:53 PM, P19 was seen by an ED physician.

On 10/1/24 at 10:54 PM, P19's ED Disposition was set to "Eloped."

P19's medical record lacked documented evidence that a pain assessment was performed during P19's ED visit.

On 12/12/24 at 10:08 AM, during an interview with S4, (ED Director of Nursing), he/she stated that in the ED pain is assessed during the second part of triage, unless the patient comes in with a complaint of pain then the pain should be assessed right away.

Based on observation, medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to implement policies and procedure for the care of suicidal patients presenting to the Emergency Department (ED) in four of four medical records (Patient (P)13, P23, P24, and P25).

Findings include:

Facility policy titled, "Patient Safety Watch Policy" last effective on 10/17/2024 states, " ... 1. Policy Statement: POLICY: Based on a patient risk assessment for potential for harm to self/and or others, the RN will place patients determined to be a danger to themselves or others or at risk for self or other injury on the appropriate patient watch level until an evaluation can be obtained by a LIP [Licensed Independent Practitioner] .... Law Enforcement Officers, family members, or visitors cannot be assigned responsibility to monitor the patient if an order for patient watch is in place. ...One-to-One Observation: For patients exhibiting behaviors that present a danger to self or others as evidenced by ...verbalizing suicide ideation with a plan and/or an overt suicide attempt ...a one-to-one observation is necessary ... 3. Every 15/30 Minute Check: requires that the patient be observed by a staff member at least once every 15/30 minutes as prescribed by the LIP for the duration of the order."

Facility policy titled, "Suicide Risk Assessment, Care and Referral" reviewed on 12/2022, states, "... II. Policy Definition: 1. ... Definitions ...b. 1:1 Observations: any staff member performing 1:1 Observation must remain within arm's length of patient, unless otherwise directed ...The on-going observation/assessment must be documented on the Observation Flow Sheet ... III. [facility name] - Emergency Department (ED): 1. Adult and Pediatric Patients a. All [facility initials] patients are screened for suicide ideation using the [ED] Screen version of the Columbia-Suicide Severity Rating Scale (C-SSRS), as part of the initial triage process. If the patient is unable to answer the question, ask the parent, guardian, or significant other ... i. High Risk: Initiate 1:1 observation and safety precautions..."

On 12/10/24 at 10:47 AM, a tour of the Transitional Care Unit (TCU) was conducted with Staff (S)1 (Director of Quality, Infection Prevention, and Patient Safety). During an interview, S1 indicated that the TCU is a locked 6-bed unit, for behavioral health patients that need further evaluation. The TCU was observed to have two staff members present which included, one Registered Nurse (RN) and one Security Officer. The unit had a census of three patients (P23, P24, and P25). During the tour, all three patients were observed without a staff member performing 1:1 observation within arm's reach.

On 12/10/24 at 10:49 AM, during an interview with S21 (RN), when questioned concerning the procedure for a suicidal patient in the TCU, S21 stated that the ratio in the TCU is 6:1 (6 patients per 1 RN). S21 explained there is also one Patient Care Technician (PCT) who is responsible for documenting the 15-minute observations for every patient, and one security guard. When questioned on the process if a patient was ordered a 1:1 observer, S21 stated that the one PCT in the TCU will be the 1:1 observer for all patients within the TCU.

On 12/11/24, a review of P25's medical record revealed the following:

P25 presented to the ED on 12/9/24 at 10:09 PM, with an arrival complaint of psych eval [psychiatric evaluation] and C-SSRS score indicated "High Risk." The RN Triage Note stated, "Patient to the ED with concerns of suicidal ideation after being found sitting in [his/her] vehicle with exhaust pipe covered and looping back to the inside of the vehicle. Patient per EMS [Emergency Medical Services] 'Was caught cheating on wife' prior to attempting to harm self. Patient denies attempt and states 'they broke into my car' -Patient in no distress." On 12/10/24 at 1:50 AM, P25's C-SSRS reassessment indicated "High Risk." The ED Physician Note from 12/10/24 at 2:32 AM, stated, "Discussed case with psychiatric resident who spoke with [his/her] attending [name]- they advise patient will ultimately need to be transferred to [facility initials] for full psychiatric evaluation but cannot be sent until labs are obtained." P25's medical record lacked documented evidence P25 was placed on 1:1 observation due to suicidal ideation/suicide attempt.

On 12/11/24 at 2:07 PM, upon interview, S1 stated that during the unit tour on 12/10/24, the TCU did not have a staff member assigned for 1:1 observation for P25. S1 confirmed that there should have been a 1:1 observation ordered for P25. S1 confirmed the Patient Care Technician [PCT] assigned to the unit ran to the lab at the time of the tour, and upon returned he/she sat at the nurse's station, not within arm's reach of P25.

On 12/12/24, a review of P13, P23, and P24's medical record revealed the following:

P13 arrived at the ED by ambulance on 12/3/24 at 7:44 PM with complaints of suicide attempt (Tylenol ingestion). At 7:50 PM, P13 was triaged and screened high risk for suicide using the Columbia Suicide Severity Rating Scale [C-SSRS]. The ED provider evaluated the patient at 7:56 PM. P13's nurse performed two additional C-SSRS screenings at 8:22 PM and 8:33 PM, to which P13 scored "high risk." P13 was given activated charcoal and acetylcysteine. P13 was transferred to a higher level of care at 11:07 PM.

On 12/12/24 at 10:45 AM, P13's medical record was reviewed with S3 (ED Chairman). Upon interview S3 stated, "I would have a 1:1 on [P13]." At 12:25 PM, S4 (Director of Nursing - DON) stated that patients who are deemed high risk are placed on 1:1 observation, changed into paper scrubs, and have their belongings searched. S4 then confirmed P13's medical record lacked documented evidence that P13 was placed on a 1:1 observation due to suicidal ideation.

P23 arrived at the ED on 12/10/24 at 2:15 AM, with arrival complaint of drug use. At 2:18 AM the triage note stated, "Pt [patient] to the ed [Emergency Department] with [town name] EMS [Emergency Medical Services] and PD [Police Department] under arrest after being found 'passed out' int he [sic] passenger side of the car. Patient denies using drugs today - patient noted to have white substance on the nose." At 2:21 AM, the "Suicide Screen - CSSRS [Columbia Suicide Severity Rating Scale" was documented as "unable to assess." At 3:01 AM, naloxone (Narcan) injection 0.1 mg [milligrams], intravenous was given. At 3:13 AM, the ED Notes stated, "pt receives [sic] sleeping, in pd [police department] custody, reacting only to sternal rub. Narcan given intravenously. Pt responsive immediatlhy [sic] When asked what substances where [sic] used tonight, pt replied 'I don't know I just wanted to die'." At 3:20 AM, the ED Provider Note stated, " ...ED Course note: After administration of Narcan, patient exhibits suicidal ideation. [He/She] reports [he/she] wants to kill [himself/herself] remains in PD custody. ... Plan Patient is placed in ED observation pending psychiatric evaluation. They remain medically cleared for psychiatric evaluation and will be re-assessed throughout their course in the ED." At 4:00 AM, the ED RN Updates documentation stated, "pt to TCU accompanied by [Local Police Department] left arm handcuffed to bed rail."

On 12/12/24 at 10:01 AM, upon interview, S4 stated the C-SSRS is completed on the initial assessment and should be reassessed at the RN's discretion, if there is a change in patient status, if patient was unable to answer and becomes more alert, or if they make a suicidal statement. S4 then stated that a patient who came in for overdose will remain in the main ED until awake, once awake patient will be reassessed for the need for 1:1 (observation). S4 confirmed that the Police cannot be the 1:1 [sitter]. During the medical record review, P23's medical record lacked evidence that 15-minute observations were completed every 15 minutes per facility policy. P23's medical record lacked evidence that P23 was provided a 1:1 observer due to suicidal ideation. During a tour on 12/10/24, P23 was observed without a 1:1 observer within arm's reach. On 12/12/24 at 10:41 AM, these findings were confirmed with S1 and S2 (Vice President Chief Medical Officer).

P24 arrived at the ED on 12/9/24 at 12:14 PM, with a complaint of "psych [psychiatric] evaluation." At 12:14 PM, the ED triage note stated, "Pt presents to ED aaox3 [awake, alert, and oriented], in no distress, c/o [complaining of] self-harm. Pt reports SI [suicidal ideation] with no plan denies HI [homicidal ideation] or auditory hallucinations. Pt states 'I don't want to live anymore, I'm tired of it all.' Hx [history] of depression states compliant with psych meds." At 12:18 PM, a C-SSRS was completed, resulting in a "Moderate Risk." At 12:37 PM, the Patient Safety Checklist was completed. At 12:46 PM, an order for Nursing - Patient monitoring safety checks every 15 minutes was placed. At 12:56 PM, the ED RN documentation stated, " ... Received pt in TCU-5, alert and oriented. Arrived tearful and crying a little. Had come to hospital for post-discharge follow-up and had told provider [he/she] was under a lot of stress and wanted to die. No plan." At 2:55 PM, the Clinical summary note stated, " ...Cardiology, Psychiatry, Neurology consults placed, patient on cardiac monitoring, one-to-one observation and decision was made to admit for further care and management."

Upon review, P24's medical record lacked documented evidence that the order for 1:1 observation was implemented. P24's medical record lacked evidence that 15-minute observations were completed every 15 minutes per facility policy. On 12/11/24, P1 confirmed that the 1:1 observation and the "Every 15 Minute Check" documentation should have been completed in the electronic medical record. S1 indicated that staff previously documented observations on the paper form but switched to electronic documentation as of September. During a tour on 12/10/24, P24 was observed without a 1:1 observer within arm's reach.

Based on medical record review, review of video surveillance, staff interviews, and review of facility documents, it was determined the facility failed to ensure that local authorities were notified of an assault incident per facility policy.

Findings include:

Facility policy titled, "Nonviolence in the Workplace" effective 6/30/23, states, " ...This policy defines what constitutes violent acts and threats, identifies potential warning signs, and processes for reporting and possible actions to be taken to ensure everyone's safety and well-being/recovery post-event. [Facility name] is committed to providing a safe, secure environment for its employees, patients, physicians, visitors, vendors, and volunteers. To that end, [facility name] works with its employees to maintain an environment that is free from violence, harassment, intimidation, threats or other disruptive behavior. [Facility name] will not tolerate such behavior and all employees are expected to report, using verge, any prohibited/disruptive behavior as described in the policy. All reported behaviors/events will be promptly reported by the person receiving the information. If substantiated, appropriate action(s) will be taken which may include ...notifying outside authorities. ...Definitions: Physical Assault: An act which inflicts bodily/emotional harm or unwanted hostile physical contact of a non-sexual or sexual nature (e.g. ...pushing, shoving ...). ...Prohibited Behaviors ...Any type of physical contact to cause harm to another or one's self (e.g. ..shoving ...) ..."

On 12/11/24, medical record review revealed Patient (P)1 presented to the Emergency Department (ED) on 11/10/24 at 9:18 AM, with a chief complaint of aggressive behavior. At 9:18 AM, the ED Provider Note stated, " ...[P1] is a 65 y.o. [year old] [male/female] with a PMHX [past medical history] of dementia, schizophrenia, HTN [hypertension], and COPD [chronic obstructive pulmonary disease], and HLD [hyperlipidemia], who presents to ED [emergency department] from [facility name] nursing home for psych [psychiatric] evaluation. Per report, patient began displaying aggressive behavior after a lover's quarrel. ...Upon ED arrival, patient is still aggressive and refusing to cooperate ...". At 9:28 AM, P1's CSSRS (Columbia Suicidal Severity Rating Scale) risk was "No Risk." At 10:08 AM, an order was placed for 1:1 observation for suicide and elopement precautions. At 5:56 PM, the ED RN (Registered Nurse) Updates, stated, " ...Patient assisted to the floor as [he/she] continued violently swinging at staff members, patient then lifted to stretcher, ER MD [medical doctor] at bedside ordered restraints and medication." At 10:00 PM, the restraints were removed. On 11/11/24 at 1:26 AM, the ED RN Note stated, "Patient is belligerent, uncooperative and aggressive. Pt [patient] was screaming and attempting to punch and swing at staff. Pt stumbled and fell backwards striking head on ground. Pt placed back in bed. MD at bedside. Multiple attempts made to de-escalate the patient and defuse the situation. Pt was resistant to all attempts to defuse. A code gray was called and the patient was placed in 4 point mechanical restraints. Medicated per MD orders. CT [computed tomography] scan ordered. All safety precautions maintained per facility protocol. Monitoring ongoing." On 11/11/24 at 7:43 AM, the CT Head final results were, "Trace acute subarachnoid hemorrhage in a right frontal sulcus." On 11/12/24 at 8:24 AM, a repeat CT of the head results stated, " ... Previously noted subarachnoid hemorrhage has resolved."

On 12/11/24 at 10:00 AM, the facility investigation of the incident was reviewed with S1. The incident involving P1 occurred on 11/11/24 at 1:26 AM. The facility reported this event to the Department of Health on 11/11/24 at 9:35 AM. An interview was conducted with S1, who stated that the incident was not reported sooner due to the staff involved, S24 (Security Officer), S25 (PCT), and S26 (RN) reporting the incident as a patient fall. Review of the statements from S25 and S26 revealed both staff reported P1 fell. S1 indicated once the video surveillance was reviewed of the incident it was determined that S24 pushed P1, causing P1 to fall and sustain an injury. S1 confirmed S24 worked the remainder of his/her scheduled shift on 11/11/24, because it was not known at the time that S24 pushed P1. S1 confirmed that on 11/12/24, S24 was furloughed pending the facilities investigation and on 11/25/24, S24 was terminated. S1 explained that S25, was required to complete education prior to returning to work but he/she never completed the education or returned to work, and therefore was terminated. S1 confirmed that S26, was not present during the incident, that he/she exited the unit, but documented as if he/she was present. S1 provided S26's Handle with Care re-education. S1 provided documentation that S26 had a meeting with leadership and was educated about documenting accurately and how to document if he/she is not a first-hand witness.

On 12/11/24 at 10:52 AM, review of the video surveillance for the Transitional Care Unit (TCU) within the ED was conducted in the presence of S1 and S23 (Security Director). The video surveillance reviewed did not have any audio recording and was not time stamped. S23 confirmed the video surveillance was from the incident involving P1 on 11/11/24. Video surveillance review revealed:

P1 and S24 were observed to be standing in front of the nurse's station facing each other. S25 (Patient Care Technician [PCT]) was observed to be standing behind the nurse's station. P1 appeared to be disheveled, with his/her scrub top half off. S25 then came around the nurse's station and stood behind P1. P1 then appeared to hit S24 in the upper chest area. S24 then pushed P1. P1 then appeared to hit S24 again. S24 then forcefully pushed P1, causing him/her to fall to the ground.

At 11:03 AM, the police investigation report dated 11/11/24 was reviewed with S1 and S23. The report lacked evidence that the facility reported to the police that S24 physically assaulted P1. S1 stated, "we thought [P1] fell, and we cannot control what is written in the police report." When asked if the police were updated on the results of the facility investigation that S24 physically assaulted P1, both S1 and S23 were unsure. At 11:10 AM, a phone interview was conducted with S5 (Administrative Director) who filed the initial police report. S5 indicated he/she filed the police report before the facility completed the investigation. When asked if S5 contacted the police after the investigation revealed that S24 assaulted P1, S5 stated, "No, I did not." S23 then stated, that he/she will file a supplement police report immediately. At 2:00 PM, S1 stated the facility contacted the local police department, and were told the officer that took the initial report would have to do the supplemental report. S1 stated they were attempting to contact the police department supervisor to assist with completing the supplemental report. On 12/12/24, P1 confirmed that the facility filed a supplemental police report.

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that a restrained patient received a face-to-face evaluation within one (1) hour after the application of restraints.

Findings include:

Facility policy titled, "Restraints- Violent and Non-Violent Non Self Destructive Procedure" effective 9/19/24, states, " ...1. Purpose Statement: To provide a standardized, organizational approach for the management of restraint which addresses regulatory compliance, patient dignity, and safety. ...Definitions: ...Licensed Practitioner: Any practitioner permitted by State Law and hospital policy as having authority to order restraints for patients. Physicians, APNs [Advanced Practice Nurse], and PAs [Physician Assistant] are LPs [licensed practitioners] have authority to order restraints. ...Face to Face: An LP must see the patient in person within 1 hour after the initiation of the intervention (regardless of whether the intervention has already been discontinued). The evaluation includes: the patients immediate situation, the patients reaction to the situation, the patients' medical and behavioral condition and the need to continue or terminate the intervention."

On 12/11/24 medical record review revealed Patient (P)1 presented to the Emergency Department (ED) on 11/10/24 at 9:18 AM, with a chief complaint of aggressive behavior. At 9:18 AM, the ED Provider Note stated, " ...[P1] is a 65 y.o. [year old] [male/female] with a PMHX [past medical history] of dementia, schizophrenia, HTN [hypertension], and COPD [chronic obstructive pulmonary disease], and HLD [hyperlipidemia], who presents to ED [emergency department] from [facility name] nursing home for psych [psychiatric] evaluation. Per report, patient began displaying aggressive behavior after a lover's quarrel. ...Upon ED arrival, patient is still aggressive and refusing to cooperate."

On 11/10/24 at 5:56 PM, the ED RN (Registered Nurse) Updates, stated, " ...Patient assisted to the floor as [he/she] continued violently swinging at staff members, patient then lifted to stretcher, ER MD [medical doctor] at bedside ordered restraints and medication." P1's medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints.

On 11/11/24 at 1:53 AM, a physician order was placed for restraints. P1's medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints.

On 11/11/24 at 8:15 AM, a nurse placed an order for restraints. P1's medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints.

On 12/11/24 at 2:00 PM, these findings were confirmed with S1.