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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance.

A-0144 PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, staff did not complete patient safety events for two of three patients reviewed who intentionally self-harmed (Patients #2 and #4). Additionally, the facility failed to implement mitigation (actions taken to reduce harm and prevent recurrence) for two of the three patients reviewed who intentionally self-harmed (Patients #2 and #3).

Based on interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, staff did not complete patient safety events for two of three patients who intentionally self-harmed (Patients #2 and #4). Additionally, the facility failed to implement mitigation (actions taken to reduce harm and prevent recurrence) for two of the three patients who intentionally self-harmed (Patients #2 and #3).

Findings include:

Facility policies:

The Incident Report-IR/Incident Reporting Process policy read, the purpose of the incident (patient safety event) reporting process is to ensure immediate actions are taken to prevent the potential for further incident/injury or incident reoccurrence. The policy defined an incident as an event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. The facility Risk Manager assumes overall responsibility for the IR/Incident Reporting process and conducts the follow-up and investigation to ensure appropriate actions are taken to prevent further incident/injury and/or reoccurrence.

The Special Precautions/Levels of Observation policy read, increased levels of observation/special precautions require an MD order. All precautions should be clearly indicated on the rounds sheet and in all handoff communication. Patients who require increased levels of supervision are placed on precautions throughout their hospitalization. High-risk behaviors may include, but are not limited to, suicidal ideations (SI), threats, or attempts, and may include self-mutilating or self-harm behaviors.

The Patient Observation Rounds policy read, patient bedroom doors, as well as hallway bathrooms, are locked when not in use. Patient bedroom doors were closed and locked during the day. According to the Q15 minute checks observation level, all patients shall be monitored every 15 minutes through the rounds/milieu observation process. The 1:1 observation level read, the Charge Nurse will initiate the 1:1 treatment plan form and interventions, and educate the patient on skills to increase safety. Interdisciplinary staff will update the treatment interventions and plan as necessary. RN's must reassess any patients on 1:1's every shift and document in the progress notes the patient's progress, response, and recommendations for continued levels of increased supervision or plans for discontinuation. The 1:1 treatment plan form will be completed daily to document justification until 1:1 is discontinued.

References:

Quality Assurance & Performance Improvement (QAPI) 2025 Plan read, the plan's objective was to provide a culture where care is delivered in a safe environment, promote safety, and prevent untoward occurrences (safety events). QA metrics for Risk Management patient safety event report findings are analyzed to identify significant events and/or opportunities to improve patient outcomes, and include specific actions and follow-up necessary to prevent and/or correct identified events and improve patient care. Safety was defined as avoiding patient harm by reducing risks in the care environment and applying patient interventions.

1. Staff failed to enter patient safety events for patients who engaged in self-harm (behaviors that caused physical harm to themselves).

A. Medical record reviews identified examples of self-harm that staff failed to report as patient safety events.

i. On 3/29/25 at 11:55 a.m., Patient #4 was admitted to the Discovery Unit (adolescent unit) after attempting to hang themselves with a metal hanger at home. During a psychiatric evaluation at 3:00 p.m., Provider #3 documented that Patient #4 was suicidal and had engaged in self-harm.

a. Review of the Psychiatric Progress Note entered on 4/2/25 at 9:10 p.m., Psychiatric Nurse Practitioner (PNP) #2 documented nursing staff had informed them Patient #4 engaged in self-harm by banging their head on the wall on the evening of 4/1/25.

Upon request, the facility was unable to provide evidence a patient safety event had been completed.

ii. On 2/19/25 at 3:16 p.m., Patient #2 was admitted to the Discovery Unit after the patient presented to the facility endorsing suicidal thoughts and a plan to overdose. According to the psychiatric evaluation performed by Provider #3 on 2/20/25 at 9:30 a.m., Patient #2 was suicidal and had engaged in self-harm.

According to the Psychiatric Progress Note entered on 2/24/25 at 3:00 p.m., PNP #2 documented that nursing staff informed them Patient #2 had used a piece of wood to engage in self-harm, resulting in injuries to the forearm.

The facility was unable to provide evidence a patient safety event had been entered on 2/24/25 for Patient #2.

These events contrasted with the Incident Reporting Process policy, which stated staff were to complete a patient safety report to ensure immediate actions were taken to prevent recurrence and reduce the risk of further harm.

B. Interviews with staff revealed that they failed to complete safety event reports when patients engaged in self-injurious behaviors.

i. On 4/3/25 at 3:03 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated safety event reports were not always completed after episodes of patient self-harm. RN #2 further stated the decision to complete a safety event report was subjective and based on the judgment of the nurse and the severity of the harm caused by the patient's behavior. RN #2 further stated a suicide attempt warranted reporting, while superficial scratches did not. However, if a patient dug deeply into their skin and caused significant bleeding, staff were expected to enter a safety event report. RN #2 stated that self-injurious behaviors could result in serious harm to the patient.

ii. On 4/2/25 at 10:31 a.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated when a patient engaged in self-injurious behavior, staff assessed the patient and determined whether wound care was needed. Manager #4 stated a patient safety event was not completed unless the self-injurious behavior resulted in severe harm, and the patient needed to be transferred out for further medical evaluation. Manager #4 stated staff were trained to complete a safety event report only if medical interventions were required beyond basic first aid. Manager #4 stated that staff reported safety events to help prevent further harm. Manager #4 stated safety event reports were important to ensure safety interventions were implemented to prevent further harm from occurring.

These interviews were in contrast with the Incident Reporting Process policy, which stated a safety event was to be completed by staff for events that resulted in an actual injury, nearly resulted in an injury, or had the potential to result in an injury to a patient.

2. The facility failed to ensure mitigation efforts, safety interventions, and preventative measures were implemented following patient safety events to reduce the risk of recurrence.

A. Review of patient safety event reports provided by the facility revealed the following:

i. On 1/16/25 at 12:15 p.m., Patient #3 became upset and tearful on the unit and took off their long-sleeved shirt. Patient #3 then wrapped the sleeves of the long-sleeved shirt around their neck. Staff observed Patient #3's behavior and reached the patient before the patient tightened the shirt around their neck. Staff initiated a code green (alert for immediate assistance for a patient experiencing a psychiatric or behavioral emergency).

According to the risk management note in the patient safety event report, the safety interventions and preventative measures implemented for Patient #3 included increased observations, a room change near the nurses ' station, and a daytime room lockout.

This contrasted with Patient #3's medical record, which revealed no evidence of a provider order for increased observations or a room relocation closer to the nurse's station.

ii. On 2/24/25 at 8:06 p.m., nursing staff found Patient #2 in their room with a bed sheet around their neck. Nursing staff intervened and removed the sheet.

According to the risk management note in the patient safety event report, Patient #2 was placed on suicide precautions and a daytime room lockout as safety measures to prevent recurrence.

The risk management note contrasted with Patient #2's medical record, which revealed Patient #2 had already been placed on suicide precautions when the safety event occurred.

Additionally, although the risk management notes indicated a daytime room lockout had been implemented as an intervention for Patients #2 and #3, this contrasted with the Patient Observation policy, which stated daytime room lockouts were standard practice for all patients.

B. Interviews with staff revealed a lack of compliance with facility policy and the implementation of preventative measures after patient safety events occurred.

i. On 4/7/25 at 12:02 p.m., an interview was conducted with the interim director of risk management (Director) #5. Director #5 stated the risk manager's responsibilities included reviewing and investigating patient safety events. They also stated that the risk manager verified which interventions and precautions were implemented after a patient safety event and documented them in the risk management notes. Furthermore, Director #5 stated that the interventions listed in the risk management note reflected the preventative measures implemented and were not recommendations for preventative measures.

ii. On 4/7/25 at 3:49 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated that they could not locate evidence of the safety interventions and precautions listed in the risk management notes in the medical records for Patients #2 and #3.

The interview with Chief Nursing Officer (CNO) #6 contradicted the facility's QAPI 2025 Plan, which stated the risk manager analyzed, reviewed, and monitored patient safety events and follow-ups to prevent, correct, and enhance patient outcomes and care delivery. Additionally, the plan defined safety as the avoidance of patient harm through risk reduction in the care environment and the application of patient interventions.