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Based on observations, staff interviews, clinical record review, facility document review, and video review, the facility:

1) Failed to ensure their security contractor (Contractor X) followed policy and procedures when security staff designated to supervise 5150 or 1799 patients (also known as Standby Procedure) in the ED were routinely assigned to monitor more than one patient at a time. This negatively impacted patient safety secondary to security staff inability to maintain, "line of sight" supervision (a straight line along which an observer has unobstructed vision) for patients determined to be a risk to themselves or others (Refer to A0084), and

2) Failed to ensure a formal risk assessment was conducted when security staff were "pulled" from other areas of the hospital to maintain 1:1 supervision (one staff for one patient) for patients who were on a 5150 or 1799 holds (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) in the Emergency Department (ED). This prevented administrative staff from being aware of the (potentially negative) impact this process had on other patients in the hospital (maternity unit). (Refer to A0084)

The cumulative effect of these systemic problem resulted in the inability to ensure security services were provided in a safe and effective manner.

Based on observations, staff interviews, clinical record review, facility document review, and video review, the facility:

1) Failed to ensure their security contractor (Contractor X) followed policy and procedures when security staff designated to supervise 5150 or 1799 patients (also called Standby Procedure) in the ED were routinely assigned to monitor more than one patient at a time. This contributed to staff inability to maintain, "line of sight" supervision (a straight line along which an observer has unobstructed vision) and to ensure patient safety for patients determined to be a risk to themselves or others; and

2) Failed to ensure a formal risk assessment was conducted when security staff was "pulled" from other areas of the hospital to maintain 1:1 supervision (one staff for one patient) for patients who were on a 5150 or 1799 holds (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) in the Emergency Department (ED). This prevented administrative staff from being aware of the (potentially negative) impact this process had on other patients in the hospital (maternity unit) and from ensuring security services were provided in a safe and effective manner.

Findings:

1) Review of facility Security Incident Report titled, "Narrative" (dated 3/3/19 at approximately 5:13 p.m.), indicated Patient 1 was brought into the ED and placed on a 5150 hold by local police.

An additional Narrative note (signed by Security Officer Y) indicated at approximately 2:45 p.m. (on 3/4/19), Patient 1 eloped (ran away) through the stairwell (in the ED) and Security officer Y and Security Officer Z ran after her (and returned her to her room). The Narrative at approximately 3:03 p.m., indicated Patient 1, "wrapped the chain that opens and closes the drappes (sic) and wrapped the chain around her neck."

Review of Patient 1's physician History and Physical note, undated, (documented by Physician AA) indicated Patient 1 had been brought to the ED for evaluation of increasing agitation and was thought to be having a manic episode (extremely elevated and excitable mood usually associated with bipolar disorder). Physician AA documented Patient 1 attempted to elope, was returned to an observed room, wrapped the curtain cord around her neck, and fell to the ground. The note revealed Patient 1 was found, "soon after" the hanging, complained of inability to breathe, and was intubated. Patient 1 was sent for an emergent CT (scan to assess her neck) and transferred to the ICU for further management.

During a tour and concurrent interview of the Emergency Department on 6/10/19 at 10:08 a.m., room 8 (where Patient 1 hung herself) had a high window and the shade's cords were elevated, out of reach if standing on the floor. The room contained ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) that included a heart monitor, bed rails, lights, television, and water faucet.

During an interview on 6/11/19 at 8:55 a.m. with Administrator C, Director E and Director F, Administrator C stated there had been thirteen 5150 patients in the ED, with two to three security guards, the afternoon Patient 1 hanged herself. She stated the facility had called for more security staff but no backups were available.

During an interview on 6/12/19 at 11 a.m., RN I stated the ED was very busy at the time of the incident (3/4/19) and Security Officer Y was watching at least two (5150) patients. RN I stated the ED got a lot of 5150 patients and they grouped them (close to each other) so security could cover more than one room. She stated the facility currently provided 1:1 (one staff to one patient) staffing for 5150 patients.

During an interview on 6/12/19 at 2 p.m., Manager H was asked what role security played in monitoring ED 5150 patients. Manager H stated security officers were assigned to watch high risk patients, 5150 patients and others. Manager H stated the staffing ratio prior to Patient 1's hanging incident was typically 1:2 (one security staff assigned to two patients). Manager H stated Security Officer Y had had three (5150) patients to monitor at the time of the hanging. He stated the ED had nine standby's (5150 or 1799 patients) and they had called in other security officers to help.

Review of facility policy titled "Management of the Mental Health Patient in the Emergency Department," subtitled, "5.0 Provisions/Procedures" (review date 8/2016 - current policy at the time of the incident) indicated, "5.21 Assess for Self-Harm - Procedures...Step 1. If a mental health patient is... on a 5150, they are automatically considered High risk for Suicide...Step 5. High Risk: Probable or definite risk or danger to self...Contact security to begin direct 1:1 observation using the Security Observation Tool/15 minute check. If additional security officers are not available trained staff may provide 1:1 direct observation and document 15 minute checks."

During an interview on 6/12/19 at 3:05 p.m., Manager D and Director F were asked to describe "continuous observation" and "Direct line of sight" observation. Manager D stated in the ED, this included 1:1 staffing, unobstructed view and included high risk and suicidal patients.

During an interview on 6/12/19 at 4:30 p.m., Security Officer K stated he was the first security contact with Patient 1 (when she arrived in the ED on 3/3/19). He stated staffing the night of 3/3/19 for 5150's was two to three patients to one security staff (not 1:1). He stated the, "new rule" was 1:1 staffing (for 5150 patients).

During an interview on 6/12/19 at 5:00 p.m., Security Officer L stated prior to the hanging incident in the ED on 3/4/19, security assignments for ED 5150 patients had been two to three patients to one security staff.

Review of the facility's Accreditation Report (AR), dated 2/26/19 - 2/28/19, (approximately four days before the hanging incident) indicated the ED had two rooms (6 and 7) and a bathroom used for the treatment of behavioral patients that contained ligature points (risks) and safety concerns (that illustrated the need for supervision of high risk patients). Identified issues in the rooms included door handles, moveable beds that could be used to barricade the door, sprinkler heads and non-security screws in all fixtures. Identified concerns in the bathroom included the door handle, grab bar, toilet plumbing, sink plumbing, faucet, paper towel dispenser and sprinkler head. The report indicated the facility did not perform a risk assessment (to identify safety issues) of non-designated ED rooms used by patients,which prevented ED staff from having, "all the tools required to ensure patient safety."

During an interview on 6/13/19 at 9 a.m., Manager D stated after the Accreditation survey, the facility implemented 1:1 staffing for standby's (5150/1799 patients) in the ED and the facility began utilizing facility staff (like ED technicians) to augment security staff.

During an interview on 6/13/19 at 9:45 a.m., Director G stated the facility had fifty full-time security staff (via contractor) and the staff had fixed schedules. When asked if the facility had identified any staffing issues related to security, he stated no security staffing issues had previously been identified. When asked if it was okay for one security staff to watch three 5150 patients, Director G stated, "I don't know." When asked how the facility ensured all patients were watched (adequately) when one security staff was required to watched three patients, Director G stated he did not have that information.

During an interview on 6/13/19 at 2:20 p.m., Security Officers M and N were asked how many 5150 patients they watched at one time prior to the hanging incident on 3/4/19. Security Officers M and N stated they mostly had two patients to watch but may take a third if that patient was easy. They stated when they covered lunch breaks, they sometimes had four 5150 patients to watch.

During the same interview, Security Officers M and N stated Security Officer Y had been watching four 5150 patients at the time of the incident. They stated watching four to five patients was, "not do-able" and could not be done safely. Security Officers M and N stated security staff were currently being pulled from 3N (maternity unit) to cover the 1:1 standby's.

During an interview on 6/19/19 at 9 a.m., Physician Q stated the ED was "normal busy" on the day of the incident and stated he was aware security officers were watching up to three patients each but watching four patients each, "seems like too many patients."

During an interview on 6/19/19 at 9:35 a.m., Director G reviewed Security officer CC's assignment titled, "Shift Activity Report" on 3/4/19 (from midnight to 8 a.m.) and an email from Security Account Manager DD (dated 6/19/19 at 8:18 a.m.). Director G agreed security Officer CC had from one to three patients at a time on his shift to monitor. When asked if 2:1 and 3:1 staffing seemed to be a pattern, Director G agreed two to three patients per one security officer seemed to be a pattern.

Review of the Security Activity Reports (indicating the number of 5150/1799 patients in the ED per shift - day, evening, and night shifts, that required 1:1 monitoring), from 2/4/19 through 3/4/19 (the one month period immediately prior to the incident), revealed security staff were routinely assigned greater than one 5150 patient at a time (up to 2-3 patients at a time).

During an interview with Vice President R (VP R), Administrators S/T/EE/FF, and Physician U (members of the Medical Executive committee and/or Leadership team) on 6/19/19 at 3:30 p.m., members were asked about oversight of Contractor X (the facility's security contractor). VP R stated the contract was reviewed by the legal department, by the Medical Executive committee annually, and by the quality department. Administrator S stated during the Accreditation Survey (2/26/19 - 2/28/19), the facility implemented changes to address identified issues. He stated the Accreditation survey team recommended 1:1 staffing for, "High Risk" patients that included continuous line of sight vision (staff were not to look away from patients for more than five seconds). Administrator S stated the facility began ligature risk mitigation, approved additional ED staffing on 2/28/19, and approved overtime in an attempt to reach the 1:1 supervision for High Risk patients.

During the same interview on on 6/19/19 at 3:30 p.m., the leadership team was asked why the 1:1 staffing (recommended by the Accreditation team) was not in place at the time of the incident on 3/4/19. Administrator S stated a solid plan was not in place for coverage and 1:1 staffing for 5150's did not occur over the weekend (between the survey team's exit on Thursday, 2/28/19 and the hanging incident on Monday, 3/4/19). Administrator C stated, "there was a gap" from Friday to Monday.

During the same interview on on 6/19/19 at 3:30 p.m., the leadership team was asked if they were aware security staffing assignments over the weeks prior to the incident indicated security staff routinely had more that one 5150 patient to watch at one time, sometime as many as three to four patients at a time. VP R stated they were not aware of the security staffing assignments.

During a viewing of the incident via video (from security camera in the hall; view of hall only) and concurrent interview on 6/20/19 at 2 p.m., Security Officer Y can be seen in the hall and nursing station outside ED room 8. Director G stated Security Officer Y was assigned four patients that included patients in rooms 6, 7, and 8 and a female patient in the hall across from the nurse's station (who did not yet have a room assignment).

2) During an interview on 6/18/19 at 10:55 a.m., Director G and Manager H were asked about the facility's current practice of pulling security officers from other areas of the hospital to maintain 1:1 security staffing for 5150 patients in the ED. Manager H stated they pulled from interior (3 North - maternity unit) and exterior (medical offices) posts. Manager H stated they very rarely pulled security from the maternity unit but stated they have had more pulling of security from maternity since the 3/4/19 incident. He stated the facility was currently hiring more security officers (through the contractor).

During the same interview on 6/18/19 at 10:55 a.m., Director G and Manager H were asked if a facility risk assessment had been conducted to assess how pulling security staff from inpatient areas impacted those areas, Manager H stated the facility had no formal risk assessment. He stated he collected data for a Huggs report (infant security) and for P-1 calls (priority #1/most urgent calls) for a monthly report. Manager H stated there was no up-tick in Huggs numbers but security response times for P-1 calls had increased twenty to thirty seconds.

During continued interview on 6/18/19 at 10:55 a.m., Manager H stated he gave his monthly report (with Huggs and P-1 data) to Director G and it was then taken to the Safety and Environment of Care committees (EOC). When asked if the facility could show that Manager H's report (that reflected decrease security response time to P-1 calls) had been addressed at the Security or EOC meetings, Director G stated he could not show that Manager H's report had been addressed because it was not documented.

Review of facility document titled, "Executive Summary" (dated 4/28/19) indicated the topic was, "Security 1:1 Staffing in the ED for psych patients at risk." The document indicated, "Identified Risks...When security roamers are pulled to the ED, other routing assigned duties are dropped."

Based on observations, staff interviews, clinical record review, facility document review, and video review, the facility failed to follow their policy and procedure and did not provide 1:1 supervision (one staff for one patient) for patients who were on a 5150 or 1799 holds(temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) in the Emergency Department (ED) when:

1) 1 of 25 sampled patients (Patient 1) wrapped the window shade's cord, located in her ED room, around her neck and hung herself. This resulted in Patient 1 losing consciousness, becoming intubated (a breathing tube was inserted into her lungs), transferring to the Intensive Care unit (ICU), and developing sepsis (potentially life-threatening condition caused by infection) and blood clots in both arms (Refer to A0144), and

2) The number of staff designated to supervise 5150 and 1799 hold patients in the ED was inadequate to provide, "line of sight" (a straight line along which an observer has unobstructed vision) supervision (Refer to A0144).

The cumulative effect of these systemic problem resulted in the facility denying patients their right to receive care in a safe setting.

Based on observations, staff interviews, clinical record review, facility document review, and video review, the facility failed to follow their policy and procedure and did not provide 1:1 supervision (one staff for one patient) for patients who were on a 5150 or 1799 holds (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) in the Emergency Department (ED) when:

1) 1 of 25 sampled patients (Patient 1) wrapped the window shade's cord, located in her ED room, around her neck and hung herself. This resulted in Patient 1 losing consciousness, becoming intubated (a breathing tube was inserted into her lungs), transferring to the Intensive Care unit (ICU), and developing sepsis (potentially life-threatening condition caused by infection) and blood clots in both arms, and

2) Security staff designated to supervise 5150 or 1799 patients in the ED were routinely assigned to monitor more than one patient at a time (as the facility policy indicated). This negatively impacted patient safety secondary to security staff inability to maintain, "line of sight" (a straight line along which an observer has unobstructed vision) supervision for patients determined to be a risk to themselves or others.

Findings:

Review of facility Security Incident Report titled, "Narrative" (dated 3/3/19 at approximately 5:13 p.m.), indicated Patient 1 was brought into the ED and placed on a 5150 hold by local police. The Narrative report revealed Patient 1 had "suicidal ideation's" (ideas) and "homicidal ideation's."

An additional Narrative note (signed by Security Officer Y) indicated at approximately 2:45 p.m. (on 3/4/19), Patient 1 eloped (ran away) through the stairwell (in the ED) and Security Officer Y and Security Officer Z ran after her (and returned her to her room). The Narrative indicated at approximately 3:03 p.m., Patient 1, "wrapped the chain that opens and closes the drappes (sic) and wrapped the chain around her neck." Security Officer Y documented he looked into Patient 1's room and saw Patient 1 leaning against the wall. He documented he entered the room, saw the chain around her neck, tried to lift her out of it and yelled for help.

Review of Registered Nurse J's (RN J) nurse's note, dated 3/4/19 at 4:19 p.m., indicated RN J heard a call for help from Security Officer Y on the afternoon of the incident. RN J documented Security Officer Y and Patient 1 were in the back, left corner of the room and Patient 1 had the window shade cord around her neck. RN J documented Patient 1 was lifted, the cord was removed and she was placed on a gurney. He documented Patient 1 had "snoring respirations" (breathing).

Review of a facility photo of Patient 1, dated 3/4/19 at 3:36 p.m., revealed Patient 1 had a pink, circular mark around the anterior (front) portion of her neck (the posterior/back portion of her neck was not visible in the photo).

Review of Patient 1's physician History and Physical note, undated, (documented by Physician AA) indicated Patient 1 had been brought to the ED for evaluation of increasing agitation and was thought to be having a manic episode (extremely elevated and excitable mood usually associated with bipolar disorder). Physician AA documented Patient 1 attempted to elope, was returned to an observed room, wrapped the curtain cord around her neck, and fell to the ground. The note revealed Patient 1 was found, "soon after" the hanging, complained of inability to breathe, and was intubated. Patient 1 was sent for an emergent CT (scan to assess her neck) and transferred to the ICU for further management.

During a tour and concurrent interview of the Emergency Department on 6/10/19 at 10:08 a.m., room 8 (where Patient 1 hung herself) had a high window and the shade's cords were elevated, out of reach if standing on the floor. The room contained ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) that included a heart monitor, bed rails, lights, television, and water faucet. A staff member was sitting in a chair and facing the patient in the room. Manager D stated the patient in room 8 was on a 5150 and the staff member was a "sitter" (watching/supervising the patient).

During an interview on 6/10/19 at 10:30 a.m., Registered Nurse BB (RN BB) stated rooms 6 and 7 were the preferred rooms for manic patients and those rooms had a camera (with display screen at the nurses desk).

During an interview on 6/11/19 at 8:55 a.m. with Administrator C, Director E and Director F, Administrator C stated there had been thirteen 5150 patients in the ED, with two to three security guards, the afternoon Patient 1 hanged herself. She stated the facility had called for more security staff but no backups were available.

During an interview on 6/12/19 at 11 a.m., RN I stated RN J was Patient 1's nurse the afternoon of the hanging and she was covering his lunch break at the time of the incident. RN I stated she was the first to arrive on the scene (after security called for help). RN I stated the ED was very busy and Security Officer Y was watching at least two (5150) patients. RN I stated she heard security yell, "help me" and when she walked into the room, she saw Security Officer Y in the corner, holding up Patient 1. RN I stated she yelled for help and started to unwrap the cord (from Patient 1's neck). She stated Patient 1 was unconscious, was not responsive, and her face and head were purplish in color.

During the same interview, RN I stated the ED got a lot of 5150 patients and they grouped them (close to each other) so security could cover more than one room. She stated the facility currently provided 1:1 (one staff to one patient) staffing for 5150 patients.

During an interview on 6/12/19 at 2 p.m., Manager H was asked what role security played in ED 5150 patients. Manager H stated security officers were assigned to watch high risk patients, 5150 patients and others. Manager H stated the staffing ratio prior to Patient 1's hanging incident was typically 1:2 (one security staff assigned to two patients). Manager H stated Security Officer Y had had three (5150) patients to monitor at the time of the hanging. He stated the ED had nine standby's (5150 or 1799 patients) and they had called in other security officers to help.

Review of facility policy titled "Management of the Mental Health Patient in the Emergency Department," subtitled, "5.0 Provisions/Procedures" (review date 8/2016 - current policy at the time of the incident) indicated, "5.21 Assess for Self-Harm - Procedures...Step 1. If a mental health patient is... on a 5150, they are automatically considered High risk for Suicide...Step 5. High Risk: Probable or definite risk or danger to self...Contact security to begin direct 1:1 observation using the Security Observation Tool/15 minute check. If additional security officers are not available trained staff may provide 1:1 direct observation and document 15 minute checks."

During an interview on 6/12/19 at 3:05 p.m., Manager D and Director F were asked to describe "continuous observation" and "Direct line of sight" observation. Manager D stated in the ED, this included 1:1 staffing, unobstructed view and included high risk and suicidal patients.

During an interview on 6/12/19 at 3:55 p.m., RN J stated he was Patient 1's nurse the afternoon of the incident. He stated Patient 1 had verbalized a desire to go home but the Social Worker decided not to lift the 5150. RN J stated Patient 1 bolted into the stairwell and Security Officer Y went down and walked her back. RN I stated Patient 1 appeared unresponsive (after the hanging) and he and Security Officer Y lifted her up while RN I untied the cord. RN J stated Patient 1 said, "I can't breath" and was moved to another room.

During an interview on 6/12/19 at 4:30 p.m., Security Officer K stated he was the first security contact with Patient 1 (when she arrived in the ED on 3/3/19). He stated staffing on 3/3/19 (the day before the incident) for 5150's was two to three patients to one security staff (not 1:1). He stated the, "new rule" was 1:1 staffing (for 5150 patients).

During an interview on 6/12/19 at 5:00 p.m., Security Officer L stated prior to the hanging incident in the ED on 3/4/19, security assignments for ED 5150 patients had been two to three patients to for one security staff.

Review of the facility's Accreditation Report (AR), dated 2/26/19 - 2/28/19, (approximately four days before the hanging incident) indicated the ED had two designated rooms (6 and 7) and a bathroom used for the treatment of behavioral patients that contained ligature points (risks) and safety concerns (that illustrated the need for supervision of high risk patients). Identified issues in the rooms included door handles, moveable beds that could be used to barricade the door, sprinkler heads and non-security screws in all fixtures. Identified concerns in the bathroom included the door handle, grab bar, toilet plumbing, sink plumbing, faucet, paper towel dispenser and sprinkler head. The report indicated the facility did not perform a risk assessment (to identify safety issues) of non-designated ED rooms used by patients,which prevented ED staff from having, "all the tools required to ensure patient safety."

During an interview on 6/13/19 at 9 a.m., Manager D stated after the Accreditation survey, the facility implemented 1:1 staffing for standby's (5150/1799 patients) in the ED and the facility began utilizing facility staff (such as ED technicians) to augment security staff.

During an interview on 6/13/19 at 9:45 a.m., Director G stated the facility had fifty full-time security staff (via contractor) and the staff had fixed schedules. When asked if the facility had identified any staffing issues related to security, he stated no security staffing issues had previously been identified. When asked if it was okay for one security staff to watch three 5150 patients, Director G stated, "I don't know." When asked how the facility ensured all patients were watched (using line of sight) when one security staff was required to watched three patients, Director G stated he did not have that information.

During an interview on 6/13/19 at 2:20 p.m., Security Officers M and N were asked how many 5150 patients they watched at one time prior to the hanging incident on 3/4/19. Security Officers M and N stated they mostly had two patients to watch but may take a third if that patient was easy. They stated when they covered lunch breaks, they sometimes had four 5150 patients to watch.

During the same interview, Security Officers M and N stated Security Officer Y had been watching four 5150 patients at the time of the incident. They stated watching four to five patients was, "not do-able" and could not be done safely. Security officers M and N stated security staff were currently pulled from 3N (maternity unit) to cover the 1:1 standby's.

During an interview on 6/19/19 at 9 a.m., Physician P had been one of Patient 1's doctors in the ICU. Physician P stated Patient 1 had been intubated after the hanging due to shortness of breath. Physician P stated Patient 1 had required large doses of sedating medicating when she was intubated and had to be restrained (tied down). Physician P stated Patient 1 developed a high fever, became septic, and required intravenous antibiotics to treat the infection while in the ICU. She stated Patient 1 developed clots in both arms while in the ICU and began taking medication to help prevent the clots from increasing. Physician P stated at the time of her discharge from the hospital, Patient 1 was taking oral antibiotics to treat her infection and aspirin to help the resolution of the clots in her arms.

During an interview on 6/19/19 at 9 a.m., Physician Q stated he was present in the ED room when Patient 1 was intubated on 3/4/19. Physician Q viewed a picture (taken by the facility after the incident) of Patient 1's neck after the hanging (dated 3/4/19 at 3:36 p.m.). When asked if Patient 1's neck potentially got worse (redness and swelling) after the photo was taken, Physician Q stated, "quite a bit" and stated physicians intubated patients after a hanging trauma because the swelling would increase (and potentially interfere with breathing).

During the same interview on 6/19/19 at 9 a.m., Physician Q stated the ED was "normal busy" on the day of the incident and stated he was aware security officers were watching up to three patients each. He stated security staff should have, "eyes on" the 5150 patients but agreed they would be unable to observe patients if one of them eloped (like Patient 1). Physician Q stated security officers watching four patients each seemed, "like too many patients."

During an interview on 6/19/19 at 9:35 a.m., Director G reviewed Security officer CC's assignment titled, "Shift Activity Report" on 3/4/19 (from midnight to 8 a.m.) and an email from Security Account Manager DD (dated 6/19/19 at 8:18 a.m.). Director G agreed security Officer CC had from one to three patients at a time on his shift to monitor. When asked if 2:1 and 3:1 staffing seemed to be a pattern, Director G agreed two to three patients per one security officer seemed to be a pattern.

Review of the Security Activity Reports (indicating the number of 5150/1799 patients in the ED per shift - day, evening, and night shifts, that required 1:1 monitoring), from 2/4/19 through 3/4/19 (the one month period immediately prior to the incident), revealed security staff were routinely assigned greater than one 5150 patient at a time (up to two to three patients at a time).

During an interview with Vice President R (VP R), Administrators S/T/EE/FF, and Physician U (members of the Medical Executive committee and/or Leadership team) on 6/19/19 at 3:30 p.m., members were asked about oversight of Contractor X (the facility's security contractor). VP R stated the contract was reviewed by the legal department, by the Medical Executive committee annually, and by the quality department. Administrator S stated during the Accreditation Survey (2/26/19 - 2/28/19), the facility implemented changes to address identified issues. He stated the Accreditation survey team recommended 1:1 staffing for, "High Risk" patients that included continuous line of sight vision (staff were not to look away from patients for more than five seconds). Administrator S stated the facility began ligature risk mitigation, approved additional ED staffing on 2/28/19, and approved overtime in an attempt to reach the 1:1 supervision for High Risk patients.

During the same interview on on 6/19/19 at 3:30 p.m., the leadership team was asked why the 1:1 staffing (recommended by the Accreditation team) was not in place at the time of the incident on 3/4/19. Administrator S stated a solid plan was not in place for coverage and 1:1 staffing for 5150's did not occur over the weekend (between the survey team's exit on Thursday, 2/28/19 and the hanging incident on Monday, 3/4/19). Administrator C stated, "there was a gap" from Friday to Monday.

During the same interview on 6/19/19 at 3:30 p.m., the leadership team was asked if they were aware security staffing assignments the month prior to the incident indicated security staff routinely had more that one 5150 patient to watch at one time, sometime as many as two to three patients at a time. VP R stated they were not aware of the security staffing assignments.

During a viewing of the incident via video (from security camera in the hall; view of hall only) and concurrent interview on 6/20/19 at 2 p.m., Security Officer Y can be seen in the hall and nursing station outside ED room 8. Director G stated Security Officer Y was assigned four patients that included patients in rooms 6, 7, and 8 and a female patient in the hall across from the nurse's station (who did not yet have a room assignment). Patient 1 can be seen eloping toward the stairwell and Security Officer Y can be seen going after her. On two additional videos (longer in length but otherwise the same footage), Security Officer Y can be see entering room 8 (when he finds Patient 1 after the hanging), staff coming to assist, and staff transferring Patient 1 to another room for medical interventions.

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse administered the medication according to policy and procedure for one of two patients (Patient 15) when three tablets of Sevelamer (a phosphate binding drug used to treat hyperphosphatemia in patients with chronic kidney disease. When taken with meals, it binds to dietary phosphate and prevents its absorption.) were left at bedside table. This failure had the potential for patient to missed taking the medication and affect other medication's absorption and efficacy.

Findings:

Review of the Clinical Record indicated Patient 15 was admitted to the facility on 5/28/19. Patient 15 was on Peritoneal Dialysis (the use the peritoneum in a person's abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte problems, and remove toxins for people with kidney failure).

During a medication observation on 6/18/19, at 9:15 a.m., Licensed Nurse B administered medications to Patient 15. After Patient 15 took the medications, Licensed Nurse B noted three tablets in a small cup at Patient 15's bedside table. Patient 15 stated the three tablets were her "Phosphorus binders" and had to be taken with food. The food tray was at bedside.

During an interview and concurrent record review on 6/18/19, at 9:19 a.m., Licensed Nurse B stated he did not leave the three tablets left at bedside. Licensed Nurse B verified from the electronic Medication Administration Record the Sevelarmer was charted given at 8:12 a.m. that morning by another nurse. Licensed Nurse B stated he usually do not leave medication at bedside and he would come back or return the medication to the pharmacy bins when patient was not ready to take it.

During an interview on 6/18/19, at 9:35 a.m., Nurse Manager A stated the medication left at bedside was not part of practice, the medication should have been given or returned to the pharmacy.

Review of the Medication order dated 5/28/19 at 2:19 p.m., indicated an order for Sevelamer Carbonate (Renvela) 2,400 milligram (mg) (Renvela 800mg per tablet) to be taken orally three times a day with meals. The order did not indicate Patient 15 was able to self-administer the Sevelamer.

Review of the Medication Administration Record (MAR) dated 6/18/19, Patient 15's MAR indicated the Sevelamer Carbonate 2,400mg was given at 8:12 a.m. The MAR indicated, "Admin Instructions: Do not chew or crush. Sevelamer binding may decrease absorption of other medications. Attempt to space administration of other ORAL medications 1 hour before or 3 hours after sevelamer."

The facility policy and procedure titled "Medication Administration (Regional)" dated 11/18 indicated, "Personnel who administer medications will follow medication practices in order to ensure patient safety." This document indicated Eight Rights of Medication Administration including right documentation, ensuring the patient has ingested the medication at the time of administration, and medications removed from the medication room of dispensing machine will not be left unattended. This document indicated medications maybe left at the bedside and self-administered when there is an order from the physician that the medication maybe left at the patient's bedside for self-administration and approved for self-administration by the Pharmacy and Therapeutics Committee.