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Based on interview and record review, the facility failed to ensure:

1. The facility was free from ligatures (used for binding something tightly), a phone cord, used by a patient (Patient 1) to attempt suicide. (refer to A-144)
2. A patient (Patient 1) was adequately supervised, to prevent Patient 1 from attempting suicide. (refer to A-144)
3. The phone with the phone cord used by a patient (Patient 1) to attempt suicide was not recessed so that it was not difficult to monitor. (refer to A-144)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the Condition of Participation for Patient's Rights were met.

Based on interview and record review, the facility failed to ensure one (1) of 79 sampled patients (Patient 1) did not attempt suicide (death caused by injuring oneself with the intent to die), by failing to:

1. Ensure the facility was free from ligatures (used for binding something tightly), a phone cord, used by Patient 1 to attempt suicide.
2. Ensure Patient 1 was adequately supervised.
3. Ensure the phone with the phone cord used by Patient 1 to attempt suicide was not recessed so that it was not difficult to monitor by facility staff.

These deficient practices resulted in Patient 1 attempting suicide by wrapping a phone cord around her neck in the hallway, subsequent transfer to another general acute care hospital (GACH) and admission to the intensive care unit (ICU, for patients who have life-threatening injuries and illnesses). Patient 1 was diagnosed at the GACH with an anoxic brain injury (a complete lack of oxygen to the brain, which results in the death of brain cells), lactic acidosis (lactic acid build up in the bloodstream when oxygen levels become low in cells within the areas of the body where metabolism takes place), and sinus tachycardia (abnormally fast heartbeat).

On 2/2/22, at 5:06 PM, an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) situation was identified due to the facility's failure to prevent Patient 1 from using a phone cord to hang herself in the hallway on 1/26/22. The IJ situation was called in the presence of the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO). A removal plan was requested from CEO and CNO.

On 2/3/22, at 4:31 p.m., the IJ was removed after verifying that an acceptable removal plan was implemented during an onsite visit (completion of the complaint validation) through observations, interview, and record review. The removal plan included the following corrective action:

a. Phone cords were removed immediately and recessed phone area was temporarily sealed. The CEO and/or designee will obtain a consultation and approval from HCAI/OSHPD (Department of Health Care Access and Information/ The Office of Statewide Health Planning and Development, promotes an equitably distributed healthcare workforce, and publishes valuable information about healthcare outcomes) prior to permanently sealing the recessed area.
b. A thorough ligature risk reassessment was completed on all patient care units to confirm that the following potential ligature risks are identified with a mitigation plan: Potential Ligature risks identified include: Six rooms on the south side of Unit 2 with light fixtures not recessed in the bathroom - mitigation plan includes removal of light fixtures. Will continue with staff awareness, staff retrained to bathroom competency and every 15-minute rounds until removal is complete. Excess linen - staff retrained to remove all excess linen from patient rooms and to monitor amount of linen provided to each patient.
c. A ligature risk assessment of all patient care units will be completed monthly. All findings will be mitigated to include staff retraining as needed.
d. Aggregated data including mitigation plan will be reported to the Patient Safety Committee, Medical Executive Committee and to the Governing Board quarterly.
e. All phone cords were removed, and the recessed area was temporarily sealed. The CEO and/or designee will obtain a consultation and approval from HCAI/OSHPD prior to permanently sealing the recessed area.
f. All Registered Nurses will be retrained to assessment and reassessment of patients for suicide risk by completing the Columbia suicide risk assessment (help establish a person's immediate risk of suicide). Training will include levels of suicide risk and interventions. Training was initiated by the CNO and/or designee on the night shift. Training included:
g. All patients assessed as high risk for suicide will have: A Columbia Lifetime Suicide Risk assessment completed to determine risk formulation and interventions after reviewed with the attending psychiatrist to determine the need for a 1:1 (one staff to one patient observation); a daily suicide risk assessment will be completed on all high-risk patients; monitored for isolative behavior (behaviors of separating oneself from others); mouth checked after medication administration (checking a patients mouth after giving them medications to ensure the medications are swallowed); consider room assignment nearest to nurses' station; monitored for excess linen and excess linen removal as necessary; all High risk patients are restricted to the Unit.
h. All patients assessed to be at moderate risk will be: monitored for isolative behavior; monitored for excess collection of linen, mouth check after medication administration, consider room assignment closer to nurses' station and contact the attending psychiatrist to discuss findings and risk level, including treatment interventions; All patients will be monitored for excess linen and removed as deemed necessary; and Consider restriction to unit after discussion with the attending psychiatrist.
i. All patients assessed at low risk will be monitored on Q15 minutes safety rounds and reassessed by the Registered Nurse every shift. Staff will be retrained to all potential ligature risks identified from the ligature risk assessment and mitigation plan. Nursing staff will not be schedule to work until training is completed.
j. All patients are searched for contraband and contraband is removed immediately. A body search for potential contraband is completed on all patients on admission. During hospitalization If contraband is identified, it is immediately removed, and the Charge registered nurse (RN) notifies the treatment team.

Findings:

During a review of the facility's Integrated Assessment (an assessment tool), dated 1/21/22, indicated Patient 1's legal status was 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness). Patient 1 was brought to the facility for fentanyl (an addictive medication used to treat severe pain) withdrawal (Physical and mental symptoms that occur after stopping or reducing intake of a drug). Patient 1 reported that she has been in touch with a music executive for past several days who stole her drugs, keys, wallet, and phone last night. Patient 1 endorses suicidal ideation (thinking about killing yourself) with plan to suffocate (die or cause to die from lack of air or inability to breathe) herself with a bag of helium (a gas). Patient 1 was irritable (having or showing a tendency to be easily annoyed or made angry) and hyperverbal (fast, increased speech).

During a review of the History and Physical (H&P), dated 1/22/22, the H&P indicated Patient 1's chief complaint (statement of symptoms that caused a patient to seek medical care) was psychotic illness (a group of serious illnesses that affect the mind). The H&P also indicated Patient 1 "was very disorganized and was given an emergency medication because of extreme psychosis (a mental disorder characterized by a disconnection from reality and disorganized thinking)."

During a review of the 72-Hour Initial Nursing Treatment Plan, dated 1/22/22, the 72-Hour Initial Nursing Treatment Plan indicated Patient 1's problem was suicidal/self-harm. Patient 1 endorsed that she had suicidal ideation with a plan to suffocate herself with a bag of helium. Patient 1's short-term goal was to not have self-harm during her stay in the facility.

During a review of the Interdisciplinary (Notes, dated 1/26/22, and timed at 4:00 p.m., the Interdisciplinary Notes indicated on 1/26/22, at 4:00 p.m., Patient 1 was requesting to be discharged from the facility. Patient 1 was quoted as stating "I need to leave right now." Patient 1 became upset when informed by staff that her discharge order was cancelled due to lack of bed availability at the receiving facility.

During a review of the Interdisciplinary (a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient) Notes, dated 1/26/22, and timed at 5:24 p.m., the Interdisciplinary Notes indicated Patient 1 was found in "distress" at the pay phone station with the phone cord around her neck. Code blue (medical emergency) was activated, as per facility protocol. CPR (Cardiopulmonary Resuscitation - an emergency life-saving procedure performed when the heart stops beating) was initiated.

During a review of the Doctor' Order Sheet, dated 1/26/22, the Doctor's Order Sheet indicated call 911, send Patient 1 to the emergency room (ER).

During a review of the GACH's H&P, dated 1/26/22, the H&P indicated Patient 1 was sent from the psychiatric facility after suicidal attempt. The psychiatric facility reported Patient 1's past medical history of psychiatric illness and was sent by emergency medical services (EMS, the ambulance) to the ER after being found down with a telephone cord hanging around her neck for an unknown duration. As per the EMS, Patient 1 was found unresponsive with sinus tachycardia on rhythm. Patient 1 received a left femoral line (a line inserted emergently into a large vein where the thigh meets the abdomen to allow rapid administration of life-saving fluids and medication) in the ER and cooling measures (cooling of the body to improve health outcomes after a period of stopped blood flow to the brain) were started. Patient 1 was admitted to the ICU, sedated (calm a person or make them sleep with medications), intubated (breathing tube inserted into the air pipes through the mouth), and on mechanical ventilation (breathing machine).

During an interview on 2/1/22, at 2:00 p.m., with the Assistant Chief Nurse Officer (ACNO), ACNO stated Patient 1 was upset about not getting discharged on 1/26/22. ACNO stated Patient 1 was loud, agitated, and irritable. The ACNO stated on 1/26/22, at 5:23 p.m., another patient (Patient 2) found Patient 1 unresponsive by the phone in the hallway and called for help. The ACNO stated, she and other staff ran to where Patient 1 was and found her with a phone cord wrapped around her neck. The ACNO stated, "we had to lift her a bit to get the phone cord off of her neck, laid her on the floor, checked for pulse, patient was unresponsive, and we began compressions." The ACNO could not verbalize whether Patient 1 being upset for a cancelled discharge could have escalated to an attempted suicide.

During an interview on 2/2/22, at 10:55 a.m., with a charge nurse (CN 1), CN 1 stated, "We never thought of the phone as a ligature. We check it only when the receiver is damaged, but it's not something we check during our rounds." CN 1 stated, Patient 1 was upset when she (Patient 1) was informed that her discharge to another facility was cancelled due to lack of bed availability.

During an interview on 2/2/22, at 10:59 a.m., CNO stated "Truly, we never identified the cord as a ligature risk because of its length." The CNO could not verbalize whether Patient 1 was monitored adequately to ensure she did not attempt suicide.

During a concurrent interview and a review of video footage, on 2/2/22, at 11:20 a.m., with CNO, CNO confirmed the following occurred (on 1/26/22) regarding Patient 1's suicide attempt:

a. At 5:09 p.m., Patient 1 approached the phone in the hallway.
b. At 5:12 p.m., Program Specialist (PST 1, assists the mental health team with patient care) stood in the hallway observing Patient 1 using the phone.
c. At 5:13 p.m., PST 1 left Patient 1 to continue rounding on other patients in their rooms.
d. At 5:23 p.m., Patient 2 found Patient 1 unresponsive near the phone.
e. At 5:24 p.m., staff (unidentified) seen running towards Patient 1 in the hallway.
f. At 5:32 p.m., paramedics team arrived on the scene.
g. At 5:44 p.m., paramedics left the scene with Patient 1.

During a concurrent interview and record review on 2/2/22, at 1:00 PM, with CEO, the facility's undated "Evidence of Standards Compliance Form" was reviewed. The "Evidence of Standards Compliance Form" indicated The Director of Plant Operations supervised the recessing of all telephones to provide privacy for the phone user (completed 1/15/2011). CEO stated, the Joint Commission (JC, an accreditation organization) cited the facility's wall-mounted phones in 2011 for lack of patient privacy. The CEO stated that the JC rejected the facility's suggestion to install side panels, as the phones were located close to patient room doorways and pose as a patient safety risk.

During a review of the facility's "Environmental/Ligature Risk Assessment" dated 2/1/22, the "Environmental/Ligature Risk Assessment" indicated the recessed phones on the units had the potential for limited visibility of patient while using phone.

During a concurrent interview and record review on 2/2/22 at 5:00 PM with CEO and CNO, the Environmental/Ligature Risk Assessment dated 2/1/22, was reviewed. The Environmental/Ligature Risk Assessment indicated the recessed phones on the units had the potential for limited visibility of patients while they used the phones. The facility's mitigation strategy to prevent suicide attempts were to remove all pay phone cords in all units and to seal all phone recessed areas. CEO stated the facility's decision to recess the phones posed a suicide attempt risk for the patients, as the phones were difficult to monitor. CNO stated the phone with the phone cords had the potential for use as a ligature. CNO stated the phones with the phone cords were not included in ongoing environmental rounds.

During a review of facility's policy & procedure (P&P) titled, "High Risk Assessment Precautions", dated 07/2019, the "High Risk Assessment Precautions" P&P indicated, "It is the policy of the facility to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu."

During a review of the facility's P&P titled, "Environmental Round (Nursing)," revised April 2019, the "Environmental Round (Nursing)" P&P indicated, "it is the policy of the facility to continuously maintain safety in all patient care areas through ongoing environmental rounds. The following list will be reviewed with each environmental round: a. ligature concerns."

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 15) had an up-to-date nursing care plan. This deficient practice had the potential to result in unidentified active psychiatric (mental) problems leading to physical or emotional harm or distress.

Findings:

During a concurrent interview and record review on 2/2/22 at 1:15 p.m., with the Chief Nursing Officer (CNO), Patient 15's "History & Physical (H&P)," dated 1/22/22 was reviewed. The H&P indicated Patient 15 was admitted on 1/21/22 for a hold due to being gravely disabled (legal status used as a basis for involuntary commitment to psychiatric facility), with no plan for self-care.

During a concurrent interview and record review on 2/2/22 at 1:20 p.m., with the CNO, Patient 15's "72-Hour Initial Nursing Treatment Plan (Initial Care Plan)," dated 1/21/22 was reviewed. The Initial Care Plan indicated Patient 15 was out of contact with reality with behavioral manifestations/observations of confusion, and behaviors such as yelling/screaming. The Initial Care Plan indicated, Patient 15 had a long-term goal of not harming herself for 72 hours, as evidenced by staff observation every 15 minutes. The Initial Care Plan indicated Patient 15 had a short-term goal to verbalize stressors for 24 hours, as evidenced by staff support daily.

During a concurrent interview and record review on 2/2/22 at 1:25 p.m., with the CNO, Patient 15's "Treatment Plan (Care Plan 1)," dated 1/24/22 was reviewed. The Care Plan 1 indicated Patient 15 had an initial goal to demonstrate decrease in inappropriate emotional/actions to no more than two times per day, with a target date of 1/30/22. Care Plan 1 indicated Patient 15 had an initial goal to demonstrate organized speech during groups and interactions with staff and peers for two days, with a target date of 1/30/22. Care Plan 1 indicated Patient 15 will take Seroquel (medication used for psychosis - a mental condition) willingly, with a target date of 1/30/22.

During a concurrent interview and record review on 2/2/22 at 1:30 p.m., with the CNO, Patient 15's "Treatment Plan (Care Plan 2)," dated 2/2/22 was reviewed. The Care Plan 2 indicated Patient 15 had a goal to follow topic of conversation for five minutes in two days, with a target date of 2/7/22. Care Plan 2 indicated Patient 15 had a goal to demonstrate decreased reaction to internal stimuli twice daily, with a target date of 2/7/22. Care Plan 2 indicated Patient 15 had a goal to attend at least 75% of daily group activities/program, with a target date of 2/7/22.

During an interview on 2/2/22, at 1:35 p.m., the CNO stated Care Plan 1 should have been updated when it was due on 1/30/22 and weekly thereafter. The CNO stated nursing care plans are utilized to identify active patient problems and formulate measurable short-term and long-term goals.

During a review of the facility's policy & procedure (P&P) titled; "Treatment Planning Protocol", dated 01/2019, the "P&P" indicated, "At a minimum of every seven (7) days, or more often as clinically indicated, a Master Treatment Plan Update will be developed/completed by the multidisciplinary team. Team collaboration involves ongoing re-assessment and evaluation of the patient response to treatment and appropriate modifications of the treatment interventions are made."