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Based on observation, interviews, facility document review, and policy review, the facility failed to ensure patient care was provided in a safe setting by ensuring high risk environmental hazards, including ligature risks were not accessible and failed to provide patient monitoring per facility policy. Immediate Jeopardy was identified for the facility's failure to provide care in a safe setting to Patient1 (P1) allowing P1 to inflict self-harm and death by hanging from a no weight limitation shower curtain bar located in P1's bathroom.
Please refer to A0144.



34230

Based on observation, interviews, facility document review, and policy review, the facility failed to ensure patient care was provided in a safe setting by ensuring high risk environmental hazards, including ligature risks were not accessible and failed to provide patient monitoring per facility policy. Immediate Jeopardy was identified for the facility's failure to provide care in a safe setting to Patient1 (P1) allowing P1 to inflict self-harm and death by hanging from a no weight limitation shower curtain bar located in P1's bathroom.

Please refer to A0144.

Based on interviews, video review, record review, and policy review, the facility failed to ensure care was provided in a safe setting by removing high risk environmental hazards, including ligature risks and failed to conduct patient monitoring per facility policy for one of six patients reviewed, Patient 1 (P1). The facility's failure to ensure the shower curtain bar in P1's room was identified as a ligature risk and failure to conduct patient monitoring per facility policy resulted in P1's ability to use a shower curtain rod to inflict harm and death. Findings include:
Review of the discharge summary located in P1's medical record indicated P1 was admitted to Potter Morris 6 (PM6) on 09/05/20 with diagnoses of unspecified psychosis and substance-related and addictive disorders.
Record review of a progress note written by EMP 113, dated 09/07/20, documented, "While rounding on another patient on unit, I responded to rapid response call from another room. Patient (pt) at that time was lying on the floor surrounded by staff, non-responsive, he was cold and lips blue, I was unable to find pulse and immediately began chest compressions until rapid response team arrived shortly after. According to staff pt was found on routine checks hanging from shower pole with what appeared to be a tie possibly from a portion of the bed sheet and was immediately cut down. Shower pole remained in place. Pt ultimately expired."
In an interview on 09/14/20 at 2:20 PM, EMP108, Director of Nursing stated that the Registered Nurse (RN) on the PM6 unit completes suicidal assessments on all patients two times a day. The assessments are conducted one per shift (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM). EMP108 said RNs work 12 hours shifts and the Mental Health Technicians (MHT) work eight-hour shifts. EMP108 stated that the MHT's are responsible for completing visual checks on every patient every 15 minutes, at a minimum. EMP108 explained the MHTs must be able to see the patient from the hallway when conducting these checks. If the MHTs are unable to visualize the patient, they must enter the patient's room to visualize the patient.
In an interview on 09/15/20 at 9:00 AM, EMP109, MHT stated that the PM6 unit was staffed during the day shift by two RNs and four MHTs. EMP109 stated EMP121 went into P1's room during rounds on 09/07/20 at approximately 11:08 AM. EMP109 said EMP121, MHT found P1 in the bathroom, behind a closed door, and called P1's name. P1 responding he/she was "OK". EMP109 said EMP121 continued rounding on other patients. EMP109 stated during EMP121's following set of rounds, at approximately 11:07 AM, EMP121 entered P1's room, did not see P1 in his/her bed, so EMP121 called out to P1, but did not get a response. EMP109 explained that EMP121 opened the bathroom door and found P1 hanging from the shower bar. EMP109 stated EMP121 called for help and additional staff responded. P1was cut down, the rapid response team was called and cardiopulmonary resuscitation started.
In an interview on 09/15/20 at 10:00 AM, EMP106, MHT stated he/she was working on 09/07/20, the day of the incident. EMP106 stated he/she was hired as an MHT with the responsibilities of patient safety, helping patients "get through what they are going through", ensuring patients take their medications, and making sure patients cause no harm to themselves or others. EMP106 said P1 was sleeping much of the morning on 09/07/20 and did come out of his/her room. P1 questioned, "How can I get out?" EMP106 said staff explained to P1 that Tuesday was the planned day of discharge, but today was not Tuesday. EMP106 said P1 appeared frustrated about not knowing what day it was.
In an interview on 09/15/20 at 10:46 AM, EMP107 stated he/she was working on 09/07/20, the day of the incident and was the primary nurse for P1. EMP107 stated on 09/06/20, P1was seeking medications and was focused on leaving the unit. EMP107 said on 09/07/20, P1 was sleeping during his/her nursing rounds and was quiet when awaken. EMP107 stated P1 ate breakfast, took medications, went back to his/her room, and was not exhibiting any suicidal ideations.
In a telephone interview on 09/15/20 at 3:30 PM, EMP120, RN stated he/she was working the night shift on 09/07/20 and provided care to P1 during the shift. EMP120 said slightly after 7:30 PM, P1 was found in the day room. A suicide and pain assessment was completed with no issues noted. EMP120 said, at that time, P1 was waiting for his/her medications and an evening snack.
An interview was scheduled on 09/15/20 at 4:00 PM with EMP121, MHT via telephone, but EMP121 did not make contact.
Review of a video tape of the PM6 unit dated 09/07/20 between the hours of 9:14 AM and 12:00 PM revealed a discrepancy in the timing of the required 15 minute visual patient checks that were being completed on P1 by the MHTs.
The video tape review showed the following: (EMP118 stated there was a few minute time delay between the video time stamp and the actual time the events occurred)
At 10:15 AM, EMP122, MHT begins rounds at the dayroom and checks on patients throughout the hallway including P1.
At 10:19 AM, EMP122's rounds concluded.
At 10:32 AM, EMP122 begins rounds at dayroom and checks on patients throughout the hallway but did not enter P1's room.
At 10:37 AM, EMP122's concluded rounds and was sitting in the hallway outside of the nurses' station.
At 10:43 AM, EMP122 goes into the nurses' station, comes back out and sits down at a workstation on wheels (WOW).
At 10:47 AM, EMP122 goes to the dayroom, comes back to the outside of the nurses' station and sits down by the WOW.
At 10:49 AM, three MHT staff are in the hallway by nurses' station.
At 10:52 AM, EMP121, MHT takes over control of the WOW.
At 11:01 AM, EMP121 begins rounds at the dayroom and stops at nurses' station in the hallway.
At 11:07 AM, EMP121 is walking up the hallway while putting on gloves and physically goes into patient rooms.
At 11:09 AM, EMP121 returns to the nurses' station area.
At 11:10 AM, EMP121 looks in the dayroom and then returns to the WOW in hallway that is outside of the nurses' station.
At 11:18 AM, EMP121 checks the dayroom and returns to the WOW.
At 11:22 AM, EMP121 begins to check patients' rooms.
At 11:23 AM, EMP 121 went into P1's room, exits running to the nurses' station and several staff members run out of the nurses' station to P1's room.
The video tape review showed there was a time period of one hour and eight minutes when P1 was not visualized by a PM6 staff member which was in contradiction to the required 15 minute visual checks to be conducted by staff per hospital policy.
Review of the hospital policy titled, "Maintaining a Safe and Therapeutic Environment," revised on 09/20/19 documented, "Purpose: To provide guidelines for the safety of patients and the maintenance of a welcoming, safe and therapeutic environment. Definition of Terms ...Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes ...Policy: It is the policy of Temple University Hospital-Episcopal Campus to provide all patients served in the Behavioral Health Services a safe place for care ...Staff adheres to practices as identified in the National Patient Safety Goals. Any staff member who observes issues in the implementation of the safety protocols must rectify the breech, immediately ensure patient safety, and report the problems to a supervisor as soon as possible ...All staff accessing the behavioral health units will utilize the safety measures that have been put into place to assure patient..safety..1. General Guidelines ...b. Routine observation of patients will occur every 15 minutes ...2. Environmental Safety Measures Each behavioral health unit has several environmental safety devices and measures in place to ensure patient safety ...f. Breakaway shower rods, shower curtain clips ...5. Rounding on Patients ...b. An assigned staff member is responsible for rounding on each patient during each shift. Using the unit rounding sheet, the staff member is expected to directly observe each patient during each shift. Using the unit rounding sheet, the staff member is expected to directly observe each inpatient ...at least every 15 minutes and document their activity on the unit rounding sheet ...g. Rounds on the unit by the staff member assigned to check each patient will be made at irregular time intervals so that patient cannot predict exactly when the next rounds will occur ..."
Review of the hospital policy titled, "Close Observation - and Suicide Precautions, Behavioral Health Inpatient Units," revised 08/20/29 stated, " ...Definition of Terms: ...Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes ...D. All inpatient are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. Patient are assessed daily by the psychiatrist as a part of their mental status examination ...G. The nursing staff documents the patient's behavior, condition and location every 15 minutes for all levels of Close Observation on the inpatient on the Close Observation in the EMR ...Scope of Responsibilities: This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety ...Procedure ...c. Level III/Routine Observations Every 15 Min.- Monitors patient every 15 minutes on the Behavioral Health inpatient units ...E. Documentation The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR ...The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close Observation form in the section labeled Registered Nurse Review."







34230

Based on interviews, video review, record review, and policy review, the facility failed to ensure care was provided in a safe setting by removing high risk environmental hazards, including ligature risks and failed to conduct patient monitoring per facility policy for one of six patients reviewed, Patient 1 (P1). The facility's failure to ensure the shower curtain bar in P1's room was identified as a ligature risk and failure to conduct patient monitoring per facility policy resulted in P1's ability to use a shower curtain rod to inflict harm and death.

Findings include:
Review of the discharge summary located in P1's medical record indicated P1 was admitted to Potter Morris 6 (PM6) on 09/05/20 with diagnoses of unspecified psychosis and substance-related and addictive disorders.

Record review of a progress note written by EMP 113, dated 09/07/20, documented, "While rounding on another patient on unit, I responded to rapid response call from another room. Patient (pt) at that time was lying on the floor surrounded by staff, non-responsive, he was cold and lips blue, I was unable to find pulse and immediately began chest compressions until rapid response team arrived shortly after. According to staff pt was found on routine checks hanging from shower pole with what appeared to be a tie possibly from a portion of the bed sheet and was immediately cut down. Shower pole remained in place. Pt ultimately expired."

In an interview on 09/14/20 at 2:20 PM, EMP108, Director of Nursing stated that the Registered Nurse (RN) on the PM6 unit completes suicidal assessments on all patients two times a day. The assessments are conducted one per shift (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM). EMP108 said RNs work 12 hours shifts and the Mental Health Technicians (MHT) work eight-hour shifts. EMP108 stated that the MHT's are responsible for completing visual checks on every patient every 15 minutes, at a minimum. EMP108 explained the MHTs must be able to see the patient from the hallway when conducting these checks. If the MHTs are unable to visualize the patient, they must enter the patient's room to visualize the patient.

In an interview on 09/15/20 at 9:00 AM, EMP109, MHT stated that the PM6 unit was staffed during the day shift by two RNs and four MHTs. EMP109 stated EMP121 went into P1's room during rounds on 09/07/20 at approximately 11:08 AM. EMP109 said EMP121, MHT found P1 in the bathroom, behind a closed door, and called P1's name. P1 responding he/she was "OK". EMP109 said EMP121 continued rounding on other patients. EMP109 stated during EMP121's following set of rounds, at approximately 11:07 AM, EMP121 entered P1's room, did not see P1 in his/her bed, so EMP121 called out to P1, but did not get a response. EMP109 explained that EMP121 opened the bathroom door and found P1 hanging from the shower bar. EMP109 stated EMP121 called for help and additional staff responded. P1was cut down, the rapid response team was called and cardiopulmonary resuscitation started.

In an interview on 09/15/20 at 10:00 AM, EMP106, MHT stated he/she was working on 09/07/20, the day of the incident. EMP106 stated he/she was hired as an MHT with the responsibilities of patient safety, helping patients "get through what they are going through", ensuring patients take their medications, and making sure patients cause no harm to themselves or others. EMP106 said P1 was sleeping much of the morning on 09/07/20 and did come out of his/her room. P1 questioned, "How can I get out?" EMP106 said staff explained to P1 that Tuesday was the planned day of discharge, but today was not Tuesday. EMP106 said P1 appeared frustrated about not knowing what day it was.

In an interview on 09/15/20 at 10:46 AM, EMP107 stated he/she was working on 09/07/20, the day of the incident and was the primary nurse for P1. EMP107 stated on 09/06/20, P1was seeking medications and was focused on leaving the unit. EMP107 said on 09/07/20, P1 was sleeping during his/her nursing rounds and was quiet when awaken. EMP107 stated P1 ate breakfast, took medications, went back to his/her room, and was not exhibiting any suicidal ideations.

In a telephone interview on 09/15/20 at 3:30 PM, EMP120, RN stated he/she was working the night shift on 09/07/20 and provided care to P1 during the shift. EMP120 said slightly after 7:30 PM, P1 was found in the day room. A suicide and pain assessment was completed with no issues noted. EMP120 said, at that time, P1 was waiting for his/her medications and an evening snack.

An interview was scheduled on 09/15/20 at 4:00 PM with EMP121, MHT via telephone, but EMP121 did not make contact.

Review of a video tape of the PM6 unit dated 09/07/20 between the hours of 9:14 AM and 12:00 PM revealed a discrepancy in the timing of the required 15 minute visual patient checks that were being completed on P1 by the MHTs.
The video tape review showed the following: (EMP118 stated there was a few minute time delay between the video time stamp and the actual time the events occurred)
At 10:15 AM, EMP122, MHT begins rounds at the dayroom and checks on patients throughout the hallway including P1.
At 10:19 AM, EMP122's rounds concluded.
At 10:32 AM, EMP122 begins rounds at dayroom and checks on patients throughout the hallway but did not enter P1's room.
At 10:37 AM, EMP122's concluded rounds and was sitting in the hallway outside of the nurses' station.
At 10:43 AM, EMP122 goes into the nurses' station, comes back out and sits down at a workstation on wheels (WOW).
At 10:47 AM, EMP122 goes to the dayroom, comes back to the outside of the nurses' station and sits down by the WOW.
At 10:49 AM, three MHT staff are in the hallway by nurses' station.
At 10:52 AM, EMP121, MHT takes over control of the WOW.
At 11:01 AM, EMP121 begins rounds at the dayroom and stops at nurses' station in the hallway.
At 11:07 AM, EMP121 is walking up the hallway while putting on gloves and physically goes into patient rooms.
At 11:09 AM, EMP121 returns to the nurses' station area.
At 11:10 AM, EMP121 looks in the dayroom and then returns to the WOW in hallway that is outside of the nurses' station.
At 11:18 AM, EMP121 checks the dayroom and returns to the WOW.
At 11:22 AM, EMP121 begins to check patients' rooms.
At 11:23 AM, EMP 121 went into P1's room, exits running to the nurses' station and several staff members run out of the nurses' station to P1's room.
The video tape review showed there was a time period of one hour and eight minutes when P1 was not visualized by a PM6 staff member which was in contradiction to the required 15 minute visual checks to be conducted by staff per hospital policy.

Review of the hospital policy titled, "Maintaining a Safe and Therapeutic Environment," revised on 09/20/19 documented, "Purpose: To provide guidelines for the safety of patients and the maintenance of a welcoming, safe and therapeutic environment. Definition of Terms ...Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes ...Policy: It is the policy of Temple University Hospital-Episcopal Campus to provide all patients served in the Behavioral Health Services a safe place for care ...Staff adheres to practices as identified in the National Patient Safety Goals. Any staff member who observes issues in the implementation of the safety protocols must rectify the breech, immediately ensure patient safety, and report the problems to a supervisor as soon as possible ...All staff accessing the behavioral health units will utilize the safety measures that have been put into place to assure patient..safety..1. General Guidelines ...b. Routine observation of patients will occur every 15 minutes ...2. Environmental Safety Measures Each behavioral health unit has several environmental safety devices and measures in place to ensure patient safety ...f. Breakaway shower rods, shower curtain clips ...5. Rounding on Patients ...b. An assigned staff member is responsible for rounding on each patient during each shift. Using the unit rounding sheet, the staff member is expected to directly observe each patient during each shift. Using the unit rounding sheet, the staff member is expected to directly observe each inpatient ...at least every 15 minutes and document their activity on the unit rounding sheet ...g. Rounds on the unit by the staff member assigned to check each patient will be made at irregular time intervals so that patient cannot predict exactly when the next rounds will occur ..."

Review of the hospital policy titled, "Close Observation - and Suicide Precautions, Behavioral Health Inpatient Units," revised 08/20/29 stated, " ...Definition of Terms: ...Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes ...D. All inpatient are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. Patient are assessed daily by the psychiatrist as a part of their mental status examination ...G. The nursing staff documents the patient's behavior, condition and location every 15 minutes for all levels of Close Observation on the inpatient on the Close Observation in the EMR ...Scope of Responsibilities: This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety ...Procedure ...c. Level III/Routine Observations Every 15 Min.- Monitors patient every 15 minutes on the Behavioral Health inpatient units ...E. Documentation The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR ...The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close Observation form in the section labeled Registered Nurse Review."

Based on interviews, observations, record review, video tape review and policy review, the facility failed to ensure patient monitoring was performed as required, failed to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice and per the facility policy, and failed to ensure that medical record documentation was reflective of actual patient condition and monitoring provided by staff. The facility's failures to provide adequate patient monitoring resulted in patient (P)1 being able to tear a sheet to make a ligature tie and commit suicide by hanging from the shower curtain rod located in the patient's bathroom. Immediate Jeopardy was identified.
Findings include:
1.The facility failed to ensure the required monitoring of all patients was provided to ensure patient safety. The facility further failed to ensure documentation was accurate to reflect the patient care provided. (Refer to A0386)

2.The facility failed to ensure that RN supervision of patient care including the staff monitoring of patients was provided in accordance with professional standards and per facility policy. (Refer to A0395)




34230

Based on interviews, observations, record review, video tape review and policy review, the facility failed to ensure patient monitoring was performed as required, failed to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice and per the facility policy, and failed to ensure that medical record documentation was reflective of actual patient condition and monitoring provided by staff. The facility's failures to provide adequate patient monitoring resulted in patient (P)1 being able to tear a sheet to make a ligature tie and commit suicide by hanging from the shower curtain rod located in the patient's bathroom. Immediate Jeopardy was identified.

Findings include:

1.The facility failed to ensure the required monitoring of all patients was provided to ensure patient safety. The facility further failed to ensure documentation was accurate to reflect the patient care provided. (Refer to A0386)

2.The facility failed to ensure that RN supervision of patient care including the staff monitoring of patients was provided in accordance with professional standards and per facility policy.

(Refer to A0395)

Based on interviews, observations, record review and policy review, the hospital failed to ensure that responsibilities for patient care on the Behavioral Health Unit MP6 are followed and that Registered Nurse (RN) oversite is proactive in ensuring that patient care is complete, effective, and safe. There were 21 patients on the unit the day of the incident. A random sample of six records were selected for review (P1, P2, P3, P4, P5, and P6). There were 17 missed incidences of 15-minute wellness checks identified from random time slots on 09/06/20 and 09/07/20. The missed wellness checks were captured on the video surveillance tapes. The missed incidences identified on video were all documented by Mental Health Technicians (MHT) as being done indicating the location and behavior of the patient visualized during the checks. As a result, a patient (P1) was discovered hanging from a makeshift shower rod made of PVC pipe secured with two S-pins. The patient was deceased. The RNs sign of on the MHT's documentation at the end of each shift. This practice placed 21 patients at risk for harm, serious injury or death as it could for all patient admitted to this unit should this practice continue.
Findings include:
In an interview on 09/14/20 at 2:15 PM, EMP 108, Chief Nursing Officer explained that a Level III requires the minimum level of observation which is q (every) 15 minutes by an MHT. This is a face-to-face observation between the MHT and the patient. RNs do not round with the MHTs. However, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The RN's are required to do the Columbia Suicide Severity Rating Scale (C-SSRS) (This is a suicide risk assessment tool that was designed to support suicide risk assessment through a series of simple, plain-language questions that anyone can ask) on every patient two times a shift, which is once every 12 hours between 7:00 AM to 7:00 PM and 7:00 PM to 7:00 PM. " They [RNs] interact with patients while giving meds. The MHTs hand off care with a verbal report at: 7 AM, 3 PM, 7 PM, and 11 PM. The MHTs have 8 hours shifts and RNs have 12-hour shifts. "
In an interview on 09/15/20 at 9:00 AM, EMP 109, MP6 Nurse Manager explained that around 11:08 AM, he [EMP 121 Mental Health Technician (MHT)] went into P1's room. EMP 121 said that P1 was in the bathroom. EMP 121 said that he called out P1's name and P1 responded. This is not in keeping with how EMP 108, Chief Nursing Officer describes what a Level III observation requires, which is a q 15-minute face-to-face observation between the MHT and the patient.
In an interview on 09/15/20 at 3:30 PM, EMP 120 (RN) explained, "I worked the night shift before the incident." EMP 120 stated "I spoke with [**] P1 in the day room sitting at the table and I did the suicide assessment [nursing assessment]". Medical record shows, "Sitter Documentation - Sun September 06, 2020 Reviewed by RN YES - FT 1947" (7:47 PM) EMP 120 stated, "We are required to do rounds once every shift."
In an interview on 09/17/20 at 7:55 PM, EMP 108 stated, "The RNs assess the patients two times a day [The RNs work 12 hour shifts and assess the patient once each shift which equates to two RN assessments each day]. They do a standard assessment that is in EPIC (an EMR software) and then a progress note. The MHTs do the rounds, vital signs, environmental rounds, and safety searches as well as any close observations [One-on-one observations]. The RNs do not accompany the MHTs on their rounds, they round PRN (As needed). They see the patients when giving meds [medications] or if the patient's need something they come to the window or tell one of the MHTs." When asked how they ensure that the MHTs are doing what they document on the medical record EMP 108 stated, "We trust that they are doing their job."
In an interview on 09/18/20 at 10:40 PM, EMP 108 stated, "The RNs do not follow the MHTs on their rounds, they have their own responsibilities and interact in many ways with the patients. The RNs could not possibly accompany the MHTs on every 15-minute round. We would have to increase the staff for that. It's just not possible."
An observation on 09/16/20 at 7:50 AM of the videotaped activity in the hallways of MP6 provided by EMP 118 showed that on 09/07/20 from 10:30 AM to 11:00 AM, P1's room was not entered by an MHT during any of the documented 15-minute wellness checks. However, documentation in the medical record showed that q 15-minute rounds were completed and documented by the MHT. The RN signs off on the MHTs documentation when they do their shift assessment by documenting in the EMR (Electronic Medical Record) the time, sitter, reviewed by RN and the RNs initials as a signature. The RNs work 12 hour shifts and do one assessment each shift. The RN is ultimately responsible for the care of the patients and failed to provide oversite of the MHTs to ensure that they were conducting wellness checks q 15 minutes, that patients observed by the MHTs as required, and that the documentation of the MHTs that the RN signed off on at the end of the shift is a true and accurate description of the care that the patients received.
A review of P1's medical record on 09/15/20 showed that Level III q 15-minute wellness checks did not occur as documented in the medical record. This finding was supported by review of video surveillance. Review of the medical record showed that q 15-minute wellness checks were not completed as required by the Behavioral Health Unit's policy for three of five 15-minute intervals prior to discovery of the incident. RNs do not round with the MHTs. However, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The hospital failed to ensure that RN responsibilities ensure direct oversite over the MHTs for patient care on the Behavioral Health Unit MP6.
A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policies and Procedures, "CLOSE OBSERVATION- AND SUICIDE PRECAUTIONS, BEHAVIORAL HEALTH INPATIENT UNITS" revised 08/20/2019 stated, "Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes. All patients who are not on a specific close level of observation will be checked by staff every 15 minutes. ... All inpatient behavioral health patients are observed routinely on every 15-minute basis. This observation includes patient's overall condition, location and behavior. Any time a patient is observed to be sleeping or resting, staff must look for the rise and fall of their chest to assure that they are breathing. In the case of the inability to witness the rise and fall of the chest, it may be necessary to awaken the patient. Documentation of rounding is in the Electronic Medical Record (EMR). ... All inpatients are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. ...The nursing staff documents the patient's behavior, condition and location every l5 minutes for all levels of Close Observation on the inpatient units ... in the EMR. The Close Observation level that each patient is on should be communicated to all staff during change of shift or any change in level.... This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety. ... Documentation: The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR. The contact staff will document the patient's behavior in the progress notes and indicate that the patient has been maintained on a close level of observation. The Registered Nurse assesses the patient twice a day in acute and once a day in extended acute, utilizing the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close Observation form in the section labeled Registered Nurse Review. At change of shift, a staff member of the oncoming and a staff member of the off-going shift will conduct rounds on the patients who are on a close level of observation." Staff were not following their policy.
A review on 09/16/20 of Temple University Hospital INC.- Episcopal Campus Behavioral Health Services Policy and Procedure, "MAINTAINING A SAFE AND THERAPEUTIC ENVIRONMENT" revised 09/20/19 stated, "Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes." Staff were not following their policy.


34230

Based on interviews, observations, record review and policy review, the hospital failed to ensure that responsibilities for patient care on the Behavioral Health Unit MP6 are followed and that Registered Nurse (RN) oversite is proactive in ensuring that patient care is complete, effective, and safe. There were 21 patients on the unit the day of the incident. A random sample of six records were selected for review (P1, P2, P3, P4, P5, and P6). There were 17 missed incidences of 15-minute wellness checks identified from random time slots on 09/06/20 and 09/07/20. The missed wellness checks were captured on the video surveillance tapes. The missed incidences identified on video were all documented by Mental Health Technicians (MHT) as being done indicating the location and behavior of the patient visualized during the checks. As a result, a patient (P1) was discovered hanging from a makeshift shower rod made of PVC pipe secured with two S-pins. The patient was deceased. The RNs sign of on the MHT's documentation at the end of each shift. This practice placed 21 patients at risk for harm, serious injury or death as it could for all patient admitted to this unit should this practice continue.

Findings include:

In an interview on 09/14/20 at 2:15 PM, EMP 108, Chief Nursing Officer explained that a Level III requires the minimum level of observation which is q (every) 15 minutes by an MHT. This is a face-to-face observation between the MHT and the patient. RNs do not round with the MHTs. However, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The RN's are required to do the Columbia Suicide Severity Rating Scale (C-SSRS) (This is a suicide risk assessment tool that was designed to support suicide risk assessment through a series of simple, plain-language questions that anyone can ask) on every patient two times a shift, which is once every 12 hours between 7:00 AM to 7:00 PM and 7:00 PM to 7:00 PM. " They [RNs] interact with patients while giving meds. The MHTs hand off care with a verbal report at: 7 AM, 3 PM, 7 PM, and 11 PM. The MHTs have 8 hours shifts and RNs have 12-hour shifts. "

In an interview on 09/15/20 at 9:00 AM, EMP 109, MP6 Nurse Manager explained that around 11:08 AM, he [EMP 121 Mental Health Technician (MHT)] went into P1's room. EMP 121 said that P1 was in the bathroom. EMP 121 said that he called out P1's name and P1 responded. This is not in keeping with how EMP 108, Chief Nursing Officer describes what a Level III observation requires, which is a q 15-minute face-to-face observation between the MHT and the patient.

In an interview on 09/15/20 at 3:30 PM, EMP 120 (RN) explained, "I worked the night shift before the incident." EMP 120 stated "I spoke with [**] P1 in the day room sitting at the table and I did the suicide assessment [nursing assessment]". Medical record shows, "Sitter Documentation - Sun September 06, 2020 Reviewed by RN YES - FT 1947" (7:47 PM) EMP 120 stated, "We are required to do rounds once every shift."

In an interview on 09/17/20 at 7:55 PM, EMP 108 stated, "The RNs assess the patients two times a day [The RNs work 12 hour shifts and assess the patient once each shift which equates to two RN assessments each day]. They do a standard assessment that is in EPIC (an EMR software) and then a progress note. The MHTs do the rounds, vital signs, environmental rounds, and safety searches as well as any close observations [One-on-one observations]. The RNs do not accompany the MHTs on their rounds, they round PRN (As needed). They see the patients when giving meds [medications] or if the patient's need something they come to the window or tell one of the MHTs." When asked how they ensure that the MHTs are doing what they document on the medical record EMP 108 stated, "We trust that they are doing their job."

In an interview on 09/18/20 at 10:40 PM, EMP 108 stated, "The RNs do not follow the MHTs on their rounds, they have their own responsibilities and interact in many ways with the patients. The RNs could not possibly accompany the MHTs on every 15-minute round. We would have to increase the staff for that. It's just not possible."

An observation on 09/16/20 at 7:50 AM of the videotaped activity in the hallways of MP6 provided by EMP 118 showed that on 09/07/20 from 10:30 AM to 11:00 AM, P1's room was not entered by an MHT during any of the documented 15-minute wellness checks. However, documentation in the medical record showed that q 15-minute rounds were completed and documented by the MHT. The RN signs off on the MHTs documentation when they do their shift assessment by documenting in the EMR (Electronic Medical Record) the time, sitter, reviewed by RN and the RNs initials as a signature. The RNs work 12 hour shifts and do one assessment each shift. The RN is ultimately responsible for the care of the patients and failed to provide oversite of the MHTs to ensure that they were conducting wellness checks q 15 minutes, that patients observed by the MHTs as required, and that the documentation of the MHTs that the RN signed off on at the end of the shift is a true and accurate description of the care that the patients received.

A review of P1's medical record on 09/15/20 showed that Level III q 15-minute wellness checks did not occur as documented in the medical record. This finding was supported by review of video surveillance. Review of the medical record showed that q 15-minute wellness checks were not completed as required by the Behavioral Health Unit's policy for three of five 15-minute intervals prior to discovery of the incident. RNs do not round with the MHTs. However, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The hospital failed to ensure that RN responsibilities ensure direct oversite over the MHTs for patient care on the Behavioral Health Unit MP6.

A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policies and Procedures, "CLOSE OBSERVATION- AND SUICIDE PRECAUTIONS, BEHAVIORAL HEALTH INPATIENT UNITS" revised 08/20/2019 stated, "Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes. All patients who are not on a specific close level of observation will be checked by staff every 15 minutes. ... All inpatient behavioral health patients are observed routinely on every 15-minute basis. This observation includes patient's overall condition, location and behavior. Any time a patient is observed to be sleeping or resting, staff must look for the rise and fall of their chest to assure that they are breathing. In the case of the inability to witness the rise and fall of the chest, it may be necessary to awaken the patient. Documentation of rounding is in the Electronic Medical Record (EMR). ... All inpatients are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. ...The nursing staff documents the patient's behavior, condition and location every l5 minutes for all levels of Close Observation on the inpatient units ... in the EMR. The Close Observation level that each patient is on should be communicated to all staff during change of shift or any change in level.... This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety. ... Documentation: The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR. The contact staff will document the patient's behavior in the progress notes and indicate that the patient has been maintained on a close level of observation. The Registered Nurse assesses the patient twice a day in acute and once a day in extended acute, utilizing the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close Observation form in the section labeled Registered Nurse Review. At change of shift, a staff member of the oncoming and a staff member of the off-going shift will conduct rounds on the patients who are on a close level of observation." Staff were not following their policy.
A review on 09/16/20 of Temple University Hospital INC.- Episcopal Campus Behavioral Health Services Policy and Procedure, "MAINTAINING A SAFE AND THERAPEUTIC ENVIRONMENT" revised 09/20/19 stated, "Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes." Staff were not following their policy.

Based on interviews, observations, record review and policy review, the registered nurses (RN)s failed to supervise the nursing care for each patient on the Behavioral Health Unit MP6. The RNs supervision of the Mental Health Technicians (MHT)s was not conducted to ensure wellness check monitoring was conducted on an ongoing basis in accordance with accepted standards of nursing practice. A sample of six patient records were selected randomly for review of the 21 patients on the unit. There were 17 missed q 15-minute wellness checks from random time slots reviewed that were documented as completed by MHTs. As a result, patient (P1) was discovered hanging from a makeshift shower curtain rod made of PVC pipe secured with two S-pins and expired.
Findings include:
In an interview on 09/14/20 at 2:15 PM, EMP108, Chief Nursing Officer explained that a Level III supervision requires the minimum level of observation which is q (every) 15 minutes by an MHT. The observation is a face-to-face observation between the MHT and the patient. EMP108 stated that the RNs do not round with the MHTs, but they do sign off on the MHTs documentation at the end of each shift. The RNs do not have a specific rounding requirement on the unit. The RNs are required to do the Columbia Suicide Severity Rating Scale (C-SSRS) (This is a suicide risk assessment tool that was designed to support suicide risk assessment through a series of simple, plain-language questions that anyone can ask) on every patient one time a shift, which is once every 12 hours between 7:00 AM to 7:00 PM and 7:00 PM to 7:00 PM. "They [RNs] interact with patients while giving meds. The MHTs hand off care with a verbal report at: 7 :00 AM, 3:00 PM, 7:00 PM, and 11:00 PM. The MHTs have 8 hours shifts and RNs have 12-hour shifts."
In an interview on 09/15/20 at 9:00 AM, EMP109, MP6 Nurse Manager explained that around 11:08 AM, he [EMP 121 MHT] went into P1's room. EMP121 said that P1 was in the bathroom. EMP121 said that he called out P1's name and P1 responded. EMP 109 stated that this is not in keeping with how EMP108, Chief Nursing Officer describes what a Level III observation requires, which is a q15-minute face-to-face observation between the MHT and the patient.
An observation on 09/16/20 at 7:50 AM of the videotaped activity in the hallways of the MP6 unit provided by EMP118 showed that on 09/07/20 from 10:30 AM to 11:00 AM, P1's room was not entered by an MHT during any of the documented 15-minute wellness checks. However, documentation in the medical record showed that q 15-minute rounds were completed and documented by the MHT. The RN signed off on the MHTs documentation at the end of the shift. The RN is ultimately responsible for the care of the patients and failed to provide oversite of the MHTs to ensure that they were conducting wellness checks q 15 minutes, that patients observed by the MHTs as required, and that the documentation of the MHTs that the RN signed off on at the end of the shift is a true and accurate description of the care that the patients received.
A review of P1's medical record on 09/15/20 showed that Level III q 15-minute wellness checks did not occur as documented in the medical record. This finding was supported by review of video surveillance. Review of the medical record showed that q 15-minute wellness checks were not completed as required by the Behavioral Health Unit's policy for three of five 15-minute intervals prior to discovery of the incident. RNs do not round with the MHTs; however, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The hospital failed to ensure that RN responsibilities ensure direct oversite over the MHTs for patient care on the Behavioral Health Unit MP6.
A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policies and Procedures, " CLOSE OBSERVATION- AND SUICIDE PRECAUTIONS, BEHAVIORAL HEALTH INPATIENT UNITS, " revised 08/20/2019 stated, " Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes. All patients who are not on a specific close level of observation will be checked by staff every 15 minutes. ... All inpatient behavioral health patients are observed routinely on every 15-minute basis. This observation includes patient's overall condition, location and behavior. Any time a patient is observed to be sleeping or resting, staff must look for the rise and fall of their chest to assure that they are breathing. In the case of the inability to witness the rise and fall of the chest, it may be necessary to awaken the patient. Documentation of rounding is in the Electronic Medical Record (EMR). ... All inpatients are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. ... The nursing staff documents the patient ' s behavior, condition and location every l5 minutes for all levels of Close Observation on the inpatient units ... in the EMR. The Close Observation level that each patient is on should be communicated to all staff during change of shift or any change in level. ... This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety. ... Documentation: The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR. The contact staff will document the patient's behavior in the progress notes and indicate that the patient has been maintained on a close level of observation. The Registered Nurse assesses the patient twice a day in acute and once a day in extended acute, utilizing the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close Observation form in the section labeled Registered Nurse Review. At change of shift, a staff member of the oncoming and a staff member of the off-going shift will conduct rounds on the patients who are on a close level of observation." Staff were not following their policy.
A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policy and Procedure, " MAINTAINING A SAFE AND THERAPEUTIC ENVIRONMENT" revised 09/20/19 stated, " Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes." Staff were not following their policy.





34230

Based on interviews, observations, record review and policy review, the registered nurses (RN)s failed to supervise the nursing care for each patient on the Behavioral Health Unit MP6. The RNs supervision of the Mental Health Technicians (MHT)s was not conducted to ensure wellness check monitoring was conducted on an ongoing basis in accordance with accepted standards of nursing practice. A sample of six patient records were selected randomly for review of the 21 patients on the unit. There were 17 missed q 15-minute wellness checks from random time slots reviewed that were documented as completed by MHTs. As a result, patient (P1) was discovered hanging from a makeshift shower curtain rod made of PVC pipe secured with two S-pins and expired.

Findings include:

In an interview on 09/14/20 at 2:15 PM, EMP108, Chief Nursing Officer explained that a Level III supervision requires the minimum level of observation which is q (every) 15 minutes by an MHT. The observation is a face-to-face observation between the MHT and the patient. EMP108 stated that the RNs do not round with the MHTs, but they do sign off on the MHTs documentation at the end of each shift. The RNs do not have a specific rounding requirement on the unit. The RNs are required to do the Columbia Suicide Severity Rating Scale (C-SSRS) (This is a suicide risk assessment tool that was designed to support suicide risk assessment through a series of simple, plain-language questions that anyone can ask) on every patient one time a shift, which is once every 12 hours between 7:00 AM to 7:00 PM and 7:00 PM to 7:00 PM. "They [RNs] interact with patients while giving meds. The MHTs hand off care with a verbal report at: 7 :00 AM, 3:00 PM, 7:00 PM, and 11:00 PM. The MHTs have 8 hours shifts and RNs have 12-hour shifts."
In an interview on 09/15/20 at 9:00 AM, EMP109, MP6 Nurse Manager explained that around 11:08 AM, he [EMP 121 MHT] went into P1's room. EMP121 said that P1 was in the bathroom. EMP121 said that he called out P1's name and P1 responded. EMP 109 stated that this is not in keeping with how EMP108, Chief Nursing Officer describes what a Level III observation requires, which is a q15-minute face-to-face observation between the MHT and the patient.

An observation on 09/16/20 at 7:50 AM of the videotaped activity in the hallways of the MP6 unit provided by EMP118 showed that on 09/07/20 from 10:30 AM to 11:00 AM, P1's room was not entered by an MHT during any of the documented 15-minute wellness checks. However, documentation in the medical record showed that q 15-minute rounds were completed and documented by the MHT. The RN signed off on the MHTs documentation at the end of the shift. The RN is ultimately responsible for the care of the patients and failed to provide oversite of the MHTs to ensure that they were conducting wellness checks q 15 minutes, that patients observed by the MHTs as required, and that the documentation of the MHTs that the RN signed off on at the end of the shift is a true and accurate description of the care that the patients received.

A review of P1's medical record on 09/15/20 showed that Level III q 15-minute wellness checks did not occur as documented in the medical record. This finding was supported by review of video surveillance. Review of the medical record showed that q 15-minute wellness checks were not completed as required by the Behavioral Health Unit's policy for three of five 15-minute intervals prior to discovery of the incident. RNs do not round with the MHTs; however, they do sign off on the MHTs documentation at the end of each shift. RNs do not have a specific rounding requirement on the unit. The hospital failed to ensure that RN responsibilities ensure direct oversite over the MHTs for patient care on the Behavioral Health Unit MP6.

A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policies and Procedures, " CLOSE OBSERVATION- AND SUICIDE PRECAUTIONS, BEHAVIORAL HEALTH INPATIENT UNITS, " revised 08/20/2019 stated, " Level III - 15 Minute Checks: This is the routine observation level for patients on the inpatient behavioral health units. Staff must observe the whereabouts/behavior/condition of patients every 15 minutes. All patients who are not on a specific close level of observation will be checked by staff every 15 minutes. ... All inpatient behavioral health patients are observed routinely on every 15-minute basis. This observation includes patient's overall condition, location and behavior. Any time a patient is observed to be sleeping or resting, staff must look for the rise and fall of their chest to assure that they are breathing. In the case of the inability to witness the rise and fall of the chest, it may be necessary to awaken the patient. Documentation of rounding is in the Electronic Medical Record (EMR). ... All inpatients are assessed twice a day by the Registered Nurse for suicide potential using the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. ... The nursing staff documents the patient ' s behavior, condition and location every l5 minutes for all levels of Close Observation on the inpatient units ... in the EMR. The Close Observation level that each patient is on should be communicated to all staff during change of shift or any change in level. ... This policy applies to all staff within the behavioral health units at Temple University Hospital - Episcopal Campus. It is the responsibility of all staff to adhere to the policy to maintain patient safety. ... Documentation: The nursing staff will document the patient's status, location and activity every 15 minutes in the EMR. The contact staff will document the patient's behavior in the progress notes and indicate that the patient has been maintained on a close level of observation. The Registered Nurse assesses the patient twice a day in acute and once a day in extended acute, utilizing the Columbia Suicide Severity Rating Scale (C-SSRS) Assessment. The Registered Nurse reviews the documentation of care provided on the Close Observation form at the end of every shift. The Registered Nurse signs the Close

Observation form in the section labeled Registered Nurse Review. At change of shift, a staff member of the oncoming and a staff member of the off-going shift will conduct rounds on the patients who are on a close level of observation." Staff were not following their policy.

A review on 09/16/20 of Temple University Hospital INC. - Episcopal Campus Behavioral Health Services Policy and Procedure, " MAINTAINING A SAFE AND THERAPEUTIC ENVIRONMENT" revised 09/20/19 stated, " Routine Precautions: Measures taken every day by all staff to maintain safety of patients and staff working with behavioral health patients. This includes direct observation of each patient on the inpatient behavioral health units at least every 15 minutes." Staff were not following their policy.

Based on interviews, observation, video tape review, and record review, the hospital did not meet the Condition of Participation for Physical Environment by failing to ensure a ligature risk free environment in the behavioral health units of the hospital. Interviews, observation, video tape review, and record review revealed a patient (P1) was able to inflict self-harm and death by hanging by using the no-weight limitation shower curtain bar located in the patient's bathroom. Immediate Jeopardy was identified.

Findings include:

The facility failed to provide care in a safe setting on the five behavioral health units with the use of no-weight limitation shower curtain bars. Interviews conducted with the staff on a behavioral health unit revealed the facility failed to provide a safe, ligature "free" environment. (Refer to A0701)


34230

Based on interviews, observation, video tape review, and record review, the hospital did not meet the Condition of Participation for Physical Environment by failing to ensure a ligature risk free environment in the behavioral health units of the hospital. Interviews, observation, video tape review, and record review revealed a patient (P1) was able to inflict self-harm and death by hanging by using the no-weight limitation shower curtain bar located in the patient's bathroom. Immediate Jeopardy was identified.

Findings include:

The facility failed to provide care in a safe setting on the five behavioral health units with the use of no-weight limitation shower curtain bars. Interviews conducted with the staff on a behavioral health unit revealed the facility failed to provide a safe, ligature "free" environment.

(Refer to A0701)

Based on interview, observation, video tape review and record review, the facility failed to ensure a ligature risk free environment was provided for patients at risk for self-harm or suicide. Patient1 (P1) was able to inflict harm and death by hanging from a non "break away" shower curtain bar in the patient's bathroom.
Findings include:
In an interview on 09/15/20 at 9:00 AM, EMP109, Nurse Manager, stated EMP121, Mental Health Technician (MHT) went into P1's room during rounds on 09/07/20 at approximately 11:08 AM. EMP109 said EMP121 located P1 in the bathroom, behind a closed door, and called P1's name with P1 responding he/she was "OK". EMP109 said EMP121continued rounding on other patients. EMP109 stated during EMP121's following set of rounds, at approximately 11:07 AM, EMP121 entered P1's room, did not see P1 in his/her bed, so EMP121 called out to P1, but did not get a response. EMP109 explained that EMP121 opened the bathroom door and found P1 hanging in the shower. EMP109 stated EMP121 called for help, which resulted in additional staff responding, staff cutting down P1 from the shower bar, attempting to revive P1 and calling for the rapid response team.
Observation was conducted on 09/14/20 at 10:15AM on the Behavioral Health Unit, Potter Morris 6 (PM6), with hospital staff of room 676. The bathroom of room 676, did not have a shower curtain bar, only two metal brackets that held the bar in place. Observation on 09/15/20 at 3:00 PM in room 676, a facility staff member obtained one of the PVC poles (shower curtain rod) and placed it in the brackets. The pole was not released when pulled on in a downward motion. Upon inspection the bar/bracket combination was homemade and not a manufactured product.
An interview on 09/17/20 at 10:40 AM with EMP116, Vice President of Operations stated that the shower curtain bar was made of polyvinyl chloride (PVC) pipe and the metal brackets were deemed "breakaway" brackets. EMP116 stated that it was not clear why the brackets did not break away due to P1's weight. EMP116 explained the hospital was converted from an acute care hospital to a behavioral health hospital between 2001 to 2002. EMP116 explained the facility did not have any record of what was done, during that time, in relation to the shower curtain bars. EMP116 stated that as a result of the incident, all PVC bars were immediately removed throughout the hospital. EMP116 said a result of the incident, the hospital hired a consultant to assist with obtaining a patient safe shower curtain system. EMP116 stated a Risk Assessment, which he/she was a leading member of the assessment team, for the PM6 unit will be completed on an annual basis. If issues are identified, action is taken immediately. EMP116 said the hospital operations staff has made attempts to locate a shower curtain rod system that is ligature resistant, based on the risk assessment, and recently piloted two different types of shower curtain rod systems on another floor. EMP116 stated they were not satisfied with the performance of the piloted shower curtain rod systems and continued to look for alternatives. EMP116 explained due to not being able to locate an acceptable replacement and the increased responsibilities due to the COVID-19 pandemic there has been a delay in obtaining the shower curtain rod system.
A review on 09/17/20 of the hospital document, "Behavioral Health Area Risk Assessment Grid" dated 10/10/19 stated, "Area of Evaluation: PM6 ...Does current rod breakaway? a. Are the mounting brackets for the rod be concerned a ligature point? Partially Met (was checked) Comments: Explore; b. Are any components of the mounting bracket removal? Partially Met (was checked) Comments: Yes, Rod; c. Can anything be used to insert in the mounting brackets causing the breaking device not to release? Partially Met (was checked) Comments: Possible; Can the current rod be removed from the wall? a) Can the current shower curtain holding brackets used as weapon? Comments: Yes, Possible; Can the existing rod (plastic) be reached from by standing on the floor? Comments: Yes; (handwritten notes at the bottom of page stated: "converting to ceiling mounted shower rods PM6, PM4, PM5, C5,4 approximate 3 month conversion").
A review on 09/17/20 of the hospital document, "Behavioral Health Area Risk Assessment Grid" dated 08/26/20 stated, "Area of Evaluation P6 ...Does the current rod breakaway? a. Are the mounting brackets for the rod be concerned a ligature point? b. Are any components of the mounting bracket removal? Comments: Breakaway rod with curtain hooks; Can the current rod be removed from the wall? a. Can the current shower curtain holding brackets be used as a weapon? Comments: replacing rod and track with breakaway hook - in process, 4 rooms completed with track ...Can the existing rod (plastic) be reached from by standing on floor? Comments: will be replacing with track."
A review of hospital policy, "Maintaining a Safe and Therapeutic Environment", revised 09/20/19 stated, "Purpose: To provide guidelines for the safety of patients and the maintenance of a welcoming, safe and therapeutic environment ...Policy: It is the policy of Temple University Hospital-Episcopal Campus to provide all patients served in the Behavioral Health Services a safe place for care ...Staff adheres to practices as identified in the National Patient Safety Goals. Any staff member who observes issues in the implementation of the safety protocols must rectify the breech, immediately ensure patient safety, and report the problems to a supervisor as soon as possible ...All staff accessing the behavioral health units will utilize the safety measures that have been put into place to assure patient..safety..1. General Guidelines ...b. Routine observation of patients will occur every 15 minutes ...2. Environmental Safety Measures Each behavioral health unit has several environmental safety devices and measures in place to ensure patient safety ...f. Breakaway shower rods, shower curtain clips ...5. Rounding on Patients ...Using the unit rounding sheet, the staff member is expected to directly observe each inpatient ...at least every 15 minutes and document their activity on the unit rounding sheet ...g. Rounds on the unit by the staff member assigned to check each patient will be made at irregular time intervals so that patient cannot predict exactly when the next rounds will occur ..."



34230

Based on interview, observation, video tape review and record review, the facility failed to ensure a ligature risk free environment was provided for patients at risk for self-harm or suicide. Patient1 (P1) was able to inflict harm and death by hanging from a non "break away" shower curtain bar in the patient's bathroom.

Findings include:

In an interview on 09/15/20 at 9:00 AM, EMP109, Nurse Manager, stated EMP121, Mental Health Technician (MHT) went into P1's room during rounds on 09/07/20 at approximately 11:08 AM. EMP109 said EMP121 located P1 in the bathroom, behind a closed door, and called P1's name with P1 responding he/she was "OK". EMP109 said EMP121continued rounding on other patients. EMP109 stated during EMP121's following set of rounds, at approximately 11:07 AM, EMP121 entered P1's room, did not see P1 in his/her bed, so EMP121 called out to P1, but did not get a response. EMP109 explained that EMP121 opened the bathroom door and found P1 hanging in the shower. EMP109 stated EMP121 called for help, which resulted in additional staff responding, staff cutting down P1 from the shower bar, attempting to revive P1 and calling for the rapid response team.

Observation was conducted on 09/14/20 at 10:15AM on the Behavioral Health Unit, Potter Morris 6 (PM6), with hospital staff of room 676. The bathroom of room 676, did not have a shower curtain bar, only two metal brackets that held the bar in place. Observation on 09/15/20 at 3:00 PM in room 676, a facility staff member obtained one of the PVC poles (shower curtain rod) and placed it in the brackets. The pole was not released when pulled on in a downward motion. Upon inspection the bar/bracket combination was homemade and not a manufactured product.

An interview on 09/17/20 at 10:40 AM with EMP116, Vice President of Operations stated that the shower curtain bar was made of polyvinyl chloride (PVC) pipe and the metal brackets were deemed "breakaway" brackets. EMP116 stated that it was not clear why the brackets did not break away due to P1's weight. EMP116 explained the hospital was converted from an acute care hospital to a behavioral health hospital between 2001 to 2002. EMP116 explained the facility did not have any record of what was done, during that time, in relation to the shower curtain bars. EMP116 stated that as a result of the incident, all PVC bars were immediately removed throughout the hospital. EMP116 said a result of the incident, the hospital hired a consultant to assist with obtaining a patient safe shower curtain system. EMP116 stated a Risk Assessment, which he/she was a leading member of the assessment team, for the PM6 unit will be completed on an annual basis. If issues are identified, action is taken immediately. EMP116 said the hospital operations staff has made attempts to locate a shower curtain rod system that is ligature resistant, based on the risk assessment, and recently piloted two different types of shower curtain rod systems on another floor. EMP116 stated they were not satisfied with the performance of the piloted shower curtain rod systems and continued to look for alternatives. EMP116 explained due to not being able to locate an acceptable replacement and the increased responsibilities due to the COVID-19 pandemic there has been a delay in obtaining the shower curtain rod system.
A review on 09/17/20 of the hospital document, "Behavioral Health Area Risk Assessment Grid" dated 10/10/19 stated, "Area of Evaluation: PM6 ...Does current rod breakaway? a. Are the mounting brackets for the rod be concerned a ligature point? Partially Met (was checked) Comments: Explore; b. Are any components of the mounting bracket removal? Partially Met (was checked) Comments: Yes, Rod; c. Can anything be used to insert in the mounting brackets causing the breaking device not to release? Partially Met (was checked) Comments: Possible; Can the current rod be removed from the wall? a) Can the current shower curtain holding brackets used as weapon? Comments: Yes, Possible; Can the existing rod (plastic) be reached from by standing on the floor? Comments: Yes; (handwritten notes at the bottom of page stated: "converting to ceiling mounted shower rods PM6, PM4, PM5, C5,4 approximate 3 month conversion").

A review on 09/17/20 of the hospital document, "Behavioral Health Area Risk Assessment Grid" dated 08/26/20 stated, "Area of Evaluation P6 ...Does the current rod breakaway? a. Are the mounting brackets for the rod be concerned a ligature point? b. Are any components of the mounting bracket removal? Comments: Breakaway rod with curtain hooks; Can the current rod be removed from the wall? a. Can the current shower curtain holding brackets be used as a weapon? Comments: replacing rod and track with breakaway hook - in process, 4 rooms completed with track ...Can the existing rod (plastic) be reached from by standing on floor? Comments: will be replacing with track."

A review of hospital policy, "Maintaining a Safe and Therapeutic Environment", revised 09/20/19 stated, "Purpose: To provide guidelines for the safety of patients and the maintenance of a welcoming, safe and therapeutic environment ...Policy: It is the policy of Temple University Hospital-Episcopal Campus to provide all patients served in the Behavioral Health Services a safe place for care ...Staff adheres to practices as identified in the National Patient Safety Goals. Any staff member who observes issues in the implementation of the safety protocols must rectify the breech, immediately ensure patient safety, and report the problems to a supervisor as soon as possible ...All staff accessing the behavioral health units will utilize the safety measures that have been put into place to assure patient..safety..1. General Guidelines ...b. Routine observation of patients will occur every 15 minutes ...2. Environmental Safety Measures Each behavioral health unit has several environmental safety devices and measures in place to ensure patient safety ...f. Breakaway shower rods, shower curtain clips ...5. Rounding on Patients ...Using the unit rounding sheet, the staff member is expected to directly observe each inpatient ...at least every 15 minutes and document their activity on the unit rounding sheet ...g. Rounds on the unit by the staff member assigned to check each patient will be made at irregular time intervals so that patient cannot predict exactly when the next rounds will occur ..."