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Based on observation, staff interview, medical record review, document review, and policy and procedure review, the facility failed to ensure there was an effective governing body that was legally responsible for the conduct of the hospital on three (3) of three (3) days of survey.

Findings Include:

Review of medical record for Patient #1 dated 1/02/2022, "Patient Care timeline ...6:47 p.m. ...ED Notes ...Pt brought to hallway 1 stretcher, pt is alert, has very flat affect ...has been thinking about hurting himself ...6:59 p.m. ED notes ...pt was found responsive in waiting room bathroom with pt personal belt around his neck and belt over the bathroom door". Patient was taken to room Z4 (in the behavioral health pod) at 7:48 p.m. where he would have 1:1 monitoring on suicide precautions by Patient Care Technician #1. During this time, the patient was given a television remote control by a security officer, assisting in the behavioral health pod. Patient was later found to have removed the AA batteries from the remote and swallowed one, which later had to be removed with colonoscopy.

Review of medical record for Patient #1, "Suicide Attempt Time Line", received from the Director Of Nursing (DON), revealed the following:
6:41 p.m. "patient enters the outside ER entrance" ...
6:42 p.m." Patient enters ER and walks to the registration desk" ...
6:48 p.m. "Patient finishes signing in and walks to the waiting area" ...
6:52 p.m., "Patient gets up from waiting room and walks to restroom" ...
6:56 p.m.-"Patient enters restroom", "Patient opens bathroom door and puts the belt over the top of the door and closes it" ...
6:56 p.m- ER staff opens door and calls for patient" ...
6:57 p.m. ER staff checks bathroom and sees belt and calls for Police assistance" ...
6:57 p.m., "Officer(name) shows up and attempts to open door"
6:58 p.m. "officer(name) opens the door and patient is just standing there ...the patient is escorted to the back by ER staff" ... .

Review of video footage of the patient arrives to the Emergency Room (ER) registration desk at 6:42 p.m. on 1/02/2022. He finishes signing in and walks to the waiting area at 6:48 p.m. At 6:52 p.m., the patient gets up from waiting area and walks to the restroom and enters the ladies' restroom. At 6:56 p.m., the patient opens the bathroom door and puts his belt over the top of the door and closes it. At 6:56 p.m., ER staff opens ER door and calls for patient. At 6:57 p.m., ER nurse checks bathroom and sees belt over the top of the door. She calls for police assistance. At 6:57p.m., a campus police officer arrives and attempts to open door, but it is locked. Officer gets the door open at 6:58 p.m., at which time, the patient is escorted to the back by ER staff.

Observation of Z-pod on 1/19/22 at 2:25 p.m., reveals that there are four (4) rooms in the pod. Outside of the rooms, but still in the pod, there is a bank of video monitors from where the patients are watched. One tech or nurse may be able to watch four (4) patients at once from these monitors.

Observation of Z-pod on 1/19/2022 at 2:25 p.m. reveals to be within arm's length of the patient, the Registered Nurse (RN) or Patient Care Assistant (PCA) would need to be either in the patient's room or in the doorway.

Interview with Accreditation and Quality RN on 1/19/2022 at 1:45 p.m. revealed that the registration form for the ED has not yet been edited. Also reveals that the Campus Police have not yet been educated about suicide precautions yet either. When asked why, she states this incident was not brought to her attention until 1/14/2022; it occurred on 1/2/2022. She is, currently, investigating why.

Interview with Chief Nursing Officer (CNO) on 1/19/2022 at 2:20 p.m. revealed that security officers are often used to assist nurses or techs in the behavioral health pod. She also states that security officers are not educated about suicide precautions.

Phone interview on 1/19/2022 at 2:58 p.m. with PCA #1, confirmed that he had not had any training on suicide precautions or 1:1 training. He also confirms that he had no idea the patient was not allowed to have the remote control on suicide precautions.

Interview with Accreditation and Quality RN on 1/19/2022 at 3:00 p.m. When asked why PCA #1 was monitoring a patient on suicidal precautions without first having been trained on suicidal precautions, she replied that the hospital had been purchased by another facility a little over a year ago. It has just come to her attention that, for some reason, not all the training and education had been disseminated to this campus. No one in the Emergency Department has had suicide education. She states that she will remedy this today.

Interview on 1/20/22 at 12:00 p.m. with Registration Specialist #1, who was at the registration window when patient came in, revealed that when the Commanding Officer (CO) told her that patient was having suicidal thoughts, she immediately told the triage nurse. She stated that she was told by the triage nurse that since patient was with his Commanding Officer, he could sit in the waiting room.

Phone interview with Registration Specialist #1, on 1/20/22 at 12:00p.m. revealed that she emailed her supervisor on 1/2/22 around 8:00p.m. to report the incident.

Interview with Registration Specialist #1's supervisor on 1/20/22 at 12:25p.m. revealed she did receive Registration Specialist #1's email. She reveals that she did not report the incident to anyone else or feel the need to make a report in Midas (program that disseminates problems to all necessary staff). Supervisor did ask Registration Specialist #1 to forward her email to the ED Charge Nurse.

Interview with CNO on 1/20/22 at 12:30p.m. reveals that ED Charge Nurse did make an incident report about the incident and told the CNO. CNO states that she did not report it to anyone else or put it in Midas. When asked why, she states, "I don't know."

Review of Patient Care Technician (PCT) #1's transcript report, dated 1/19/2022, reveals that he has had no training in Suicide Precautions or 1:1 Observation.

Review of document dated 1/19/22, shows that 57 people in the Emergency Department have been assigned the education entitled, "Suicide-Understanding Suicide," with a due date of 2/2/2022.

Review of Governing Body Bylaws, dated 1/27/21, reveals "the Board has the responsibility to direct the course of Singing River Health System through the establishment of periodic review of its missions, vision, and goals ...to ensure quality patient care ...the Board may delegate some duties ...but as the policy maker and governing board of the Singing River Health System, the Board remains ultimately responsible ...the functions of the board include ...to provide the resources necessary for the competent and efficient delivery of healthcare and wellness services."

Review of "Symptoms Needing Immediate Action," dated 10/29/21, reveals "when patients present to the ED with potential life-threatening symptoms, the triage nurse must be alerted immediately. Threatening harm to self or others is one of these symptoms.

Review of "Suicide Room Checklist," no date, reveals "in the Emergency Room, the triage nurse should take the patient immediately to a room. From the time the patient checked in until the nurse came to call the patient back was approximately eight (8) minutes, according to the suicide attempt timeline.

Review of "Observation and Precautions - Behavioral Health Services, dated 7/2020, states "One to One Observation is maintained at all times by a specifically assigned employee (RN or PCA) who is constantly with the patient and is never farther than an arm's length from the patient ...".

Review of facility's Root Cause/Preventative Analysis (no date) related to this incident revealed "Strategies for Improvement: Action Item #1: Edit arrival form to include radio button question related to self-harm or harm to others ...Action Item #2: Education of 100% of campus police ...campus police should not provide anything to any patient without clearing it with clinical staff ...".

Based on observations, staff interviews, medical record review, document review, and policy and procedure review, the facility failed to ensure that each patient's rights were protected on three (3) of three (3) survey days: Patient #1.

Findings Include:

Cross-refer to A-0043 for the facility's failure to ensure that patient's rights were promoted and protected.

Based on observations, staff interviews, medical record review, document review, and policy and procedure review, the facility failed to ensure patient's right to receive care in a safe setting.

Findings Include:

Cross-refer to A-0115 for facility's failure to ensure patient's rights were promoted and protected.

Based on observation, staff interview, medical record review, document review, and policy and procedure review, the facility failed to ensure the organized Nursing Service was following Nursing Service policies, patient care policies, and staff education and training policies, and ensured the implementation of Nursing Service job descriptions on three (3) of three (3) survey days.

Findings Include:

Cross-refer 0043 for facility's failure to ensure Nursing Services was following Nursing Service, patient care, and staff education and training policies and ensuring the implementation of job descriptions.

Based on observation, staff interview, medical record review, document review, and policy and procedure review, the facility failed to ensure the Director of Nursing Services provided for adequate supervision and evaluation of all nursing personnel on three (3) of three (3) survey days.

Findings Include:

Cross-refer to A-0385 for facility's failure to ensure Director of Nursing (DON) services provided supervision and evaluation of nursing personnel.

Based on observation, staff interview, medical record review, document review, and policy and procedure review, the facility failed to ensure the emergency needs of patient in accordance with acceptable standards of service in one (1) of one (1) medical record reviewed: Patient #1.

Findings Include:

Cross-refer to A-0043 for facility's failure to ensure emergency needs of patients.

Based on observation, staff interview, medical record review, document review, and policy and procedure review, the facility failed to ensure nursing personnel were qualified in emergency care to meet written emergency procedures and needs anticipated by the facility for three (3) of three (3) days of survey.

Findings Include:

Cross-refer to A-1100 for facility's failure to ensure personnel were qualified to meet emergency procedures and needs.