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Based on document review, observation, and interview, it was determined that for 4 of 4 BHU (Behavioral Health Units - 12th floor, 14th floor, 15th floor and 16th floor), the Hospital failed to ensure that ligature risks were removed as required. This potentially placed all current and future suicidal patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that ligature risks were removed as required. (A-144 A)





An Immediate Jeopardy (IJ) was identified on 7/29/19 for the Hospital's failure to remove ligature risks. This failure potentially placed all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 7/31/19 at 11:00 AM,during a meeting with the Director of Quality, Chief Nursing Officer, Operations Director (Patient Care Services), Chief Executive Officer (by phone), Director of Behavioral Health and Chief Medical Officer. The IJ was not removed by the Hospital by the survey exit date of 8/1/19.

Also, the Condition of Patient Rights was not met as evidenced by:

2. The Hospital failed to ensure that ligature risks were removed for 3 of 3 Children's Behavioral Health Units (3 North Child/Adolescent, 9 South Child/Adolescent and 3 South Child/Adolescent). (A-144B)

A. Based on document review, observation, and interview, it was determined that for 4 of 4 Adult Behavioral Health Units (12th floor, 14th floor, 15th floor, 16th floor) the Hospital failed to ensure that ligature risks were removed as required. This has the potential to affect the safety of the current psychiatric patients (50 out of the 90 patients are on suicide precautions) and any future psychiatric patients who become suicidal.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 7/29/19, and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. The Hospital's policy titled, "Suicide Precautions" (approved 5/2019 ), was reviewed on 7/29/19. The policy required, "...Suicide precautions will be initiated and potentially dangerous items will be removed...)"

3. On 7/29/19, Pt #1's clinical record was reviewed, and the patient had a diagnosis of major depression. On 7/29/19 at 10:30 AM, Pt #1 was observed alone in his room with the door closed. Pt #1 had oxygen tubing (approximately 12 feet in length) with oxygen being administered through an oxygen flow meter (flow control valve to regulate the flow of oxygen) on the wall. The oxygen tubing and oxygen flow meters are both ligature risks and could be used for hanging by the patient on the unit. The physician orders dated 7/23/19 indicated the following "...Suicide precautions..." Pt #1's room had 4 side rails, a head board and a foot board that could be used for hanging. Pt #1 was on every 15 minute monitoring.

-Pt #1's Psychiatric Evaluation dated 7/24/19 at 11:31 AM indicated "...Pt #1 presents to the Hospital for psychiatric evaluation for suicidal ideation, planned to jump into traffic. Pt #1 states he is sad and depressed..."

- The Social Worker's (E # 13) note dated 7/25/19 at 9:53 AM indicated "...Pt #1 stating that he feels depressed and that his medication hasn't helped him yet..."

- The Social Worker's (E # 13) note dated 7/26/19 at 4:00 PM indicated "...Pt #1 states that he still feels too depressed to discuss discharge plans..."

- The Mental Health Counselor's (E #14) note dated 7/28/19 at 8:41 PM indicated "...Pt #1 displayed depressed, anxious and labile mood, isolative and withdrawn to self. Pt #1 appeared confused, preoccupied with own, calm and guarded..."

- Pt #1's plan of care note dated 7/29/19 at 4:40 AM indicated "...Pt #1 from home due to suicidal ideation...Maintained close observations for suicide and assault precautions throughout the shift..."

4. On 7/29/19 at 10:35 AM, an interview was conducted with Pt #1. Pt #1 stated, "I'm suicidal and my medication is not working." The Manager of the 12th Floor Behavioral Unit (E #1) was present for the interview with Pt #1.

5. On 7/31/19 at 10:30 AM, an interview was conducted with the Director of Psychiatric Services (E #8). E #8 stated that it should be ok for a suicidal patient to be alone in a room with the door closed with 12 feet of oxygen tubing if the patient is not high risk for suicide. E #8 stated that patients are assessed for suicide risk based on the Columbia Suicide Severity Rating Scale.

6. On 7/30/19 at 1:00 PM, an observational tour was conducted on the 15th floor Adult Behavioral Health Unit. Sixteen of the 27 patients were on suicide precautions. Rooms 1504, 1505, 1530, 1532 and 1533 had 4 side rails. Rooms 1505, 1519, 1520 and 1527 had toilet pipes approximately 3 feet in length that were a ligature risk.

7. On 7/30/19, between 12:38 PM and 1:20 PM, an observational tour was conducted on the 16th floor Adult Behavioral Health Unit. There were 22 patients currently on census, of which 12 were on suicide precautions. No suicidal patients were on 1:1 monitoring (1 staff constantly monitoring 1 patient). There were 30 patient rooms and all patient rooms were private (1 bed per room). The following ligature risks were identified: 4 of the 30 beds (in rooms #1617, #1634, #1635, and #1636) were moveable, had 4 open side rails, a headboard, and a footboard. Patient entry room doors were unlocked.

8. On 7/30/19, between 1:22 PM and 1:55 PM, an observational tour was conducted on the 14th floor Adult Behavioral Health Unit. There were 20 patients currently on census, of which 10 were on suicide precautions. One suicidal patient was on 1:1 monitoring (1 staff constantly monitoring 1 patient). There were 29 patient rooms and all patient rooms had a bathroom. The following ligature risks were identified:
- Rooms #1414 and #1424 had a curved faucet with separate protruding handles to control hot and cold
water.
- Rooms #1426 and #1435 had a protruding knob in the shower to control water flow and temperature.
- The bathroom doors were not locked, when not in use.

9. On 7/29/19 at 10:00 AM, an observational tour was conducted on the 12th floor Behavioral Unit. There was 1 semi-private (2 beds in each room) patient room and 24 private rooms on the BHU. There were 26 patients on the census. 12 of 26 patients on suicide precautions. Ligature risks were identified as follows:

- Patient rooms: 1201, 1202, 1203, 1214, 1216, 1219, 1220, 1221, 1222, 1223, 1224, 1225, 1226, 1227, 1228, 1230, 1231, 1232, 1233, 1234, 1235, 1236, 1237, 1238 & 1239 had 4 side rails, a head board and a foot board that were ligature risks and could be used for hanging by the patients on the unit.

-Patient rooms (1236 and 1237) had approximately 3 feet of toilet piping that was a ligature risk and could be used for strangulation by the patients on the unit.

10. On 7/29/19 at 11:00 AM, an interview was conducted with the Manager of the Behavioral Health Unit (E #1). E#1 stated that the Hospital is working toward eliminating the toilet pipes. E #1 stated that removal of the ligature risks is a work in progress.

B. Based on document review, observation and interview, it was determined that for 3 of 3 Children Behavioral Health Units (3 North Child/Adolescent, 9 South Child/Adolescent, and 3 South Child/Adolescent), the Hospital failed to ensure that ligature risks were removed as required. This has the potential to affect the safety of the current psychiatric patients (15 out of 24 patients on suicide precautions on 7/29/19) and any future psychiatric patients who become suicidal.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 7/29/19, and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. The Hospital's policy titled, "Suicide Precautions" (approved 5/2019 ), was reviewed on 7/29/19. The policy required, "...Suicide precautions will be initiated and potentially dangerous items will be removed...)"

3. On 7/29/19 at 1:15 PM, an observational tour was conducted in the 3 North Child/Adolescent Unit. Sixteen of 16 patient bathrooms had toilet pipes, approximately 3 feet in length and the bathroom sinks had handles and a faucet, that were ligature risks. There were 10 of 17 patients on the 3 North Child/Adolescent Unit on Suicide Precautions (SP). All patient room entry and bathroom doors were locked, while not in use.

4. On 7/29/19 at 1:50 PM, an observational tour was conducted in the 9 South Child/Adolescent Unit. Two of 10 bathrooms had toilet pipes, approximately 3 feet in length and the bathroom sinks had handles and a faucet, that were ligature risks. There were 5 of 7 patients on the 9 South Child/Adolescent Unit on SP. No suicidal patients were assigned to the rooms where the ligature risks were present.

5. On 7/30/19 at 12:55 PM, an observational tour was conducted in the 3 South Child/Adolescent Unit. The Unit was closed for remodeling and no patients were on the locked Unit. Ligature risks were being removed. Fourteen of 14 patient bathrooms had toilet pipes, approximately 1 foot in length and the bathroom sinks had handles and a faucet, that were ligature risks. Ten of 14 bathroom doors were made from solid wood with flat tops, fitted in solid metal frames, that could be used for ligature attachment.

6. On 7/31/19 at 10:35 AM, an interview was conducted with the Director of Behavioral Health (E #8). E #8 stated that the suicidal patients are protected from the ligature risks by frequent suicide assessment and precautions for levels of suicide risk. High risk suicidal patients receive 1:1 monitoring (1 staff assigned to 1 patient). Safety checks (visualization of patients) are conducted every 15 minutes and the Registered Nurse makes rounds each hour.

Based on document review, observation, and interview, it was determined that for 3 of 3 Registered Nurses (E#2, E#5 and E#6) on the 14th floor Adult Behavioral Health Unit (ABHU), the Hospital failed to ensure that staff followed safe medication administration practices as required.

Findings include:

1. The Hospital's policy titled, "Medication Administration" (revised 12/14/2018), was reviewed on 7/29/19 and required, "... In order to minimize potential for medication administration errors, medications should be removed: i. For one (1) patient at a time. ii. Only at the time they are needed for administration... Non-Time Critical Medications [with] Dosing interval of daily or every 24 hours: Administer within 2 hours before or after the scheduled time... Individual authorized to administer medication will carry one patient's medications to the bedside/patient... If bar-code scanning technology is available, personnel administering the medication will scan the patient's barcode located on their wristband then scan the medication label to verify that the appropriate medication is being administered... Date and time of administration is documented on the electronic medication administration record (eMAR) when the patient identification barcode and the medication barcode are scanned... If a patient refuses medication... Return unused, unopened medication to ADC [automated dispensing cabinets] or to the pharmacy..."

2. An observational tour of the 14th Floor Adult Behavioral Health Unit (ABHU) was conducted on 7/29/19, between 9:50 AM and 11:45 AM. A Registered Nurse (RN / E#2) was observed sitting at the nurse's station charting on the computer between approximately 10:20 AM to 10:55 AM. At approximately 10:55 AM, E#2 went to the automated medication dispensing machine and pulled out a tablet of ibuprofen (pain medication). At approximately 11:00 AM, E#2 went into Pt. #17's room, with a small white binder, to administer the ibuprofen. The small white binder contained two medications: quetiapine (used to treat certain mental/mood conditions) for Pt. #18 and metoprolol (used to treat high blood pressure) for Pt. #19.

3. The clinical record of Pt. #18 was reviewed on 7/29/19, at approximately 11:10 AM, and the patient had a diagnosis of suicide ideation. The MAR (medication administration record) indicated that on 7/29/19 at 8:33 AM, the quetiapine was not given due to patient refusal, but Pt. #18's quetiapine was still in E #2's binder.

4. The clinical record of Pt. #19 was reviewed on 7/29/19, at approximately 11:15 AM, and the patient had a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A nursing message (from E#2) dated 7/29/19 at 8:38 AM included, " ...metoprolol ... Please send. Thank you!" A reply from a Pharmacist (E#3) on 7/29/19 at 8:43 AM included, "Re-dispensed a dose and tubed it up. Thank you." Pt. #19's MAR dated 7/29/19, included that metoprolol was administered at 8:53 AM, but Pt. #19's metoprolol was still in E #2's binder.

5. An interview was conducted with the Registered Nurse (E#2) on 7/29/19, at approximately 11:29 AM. E#2 stated that she always scans the patient's identification band and the medication's barcode when administering medications. When asked about the medications in the binder, E#2 stated that Pt. #18 refused the quetiapine this morning and E#2 did not have time to place the medication back in the dispensing machine. When asked about Pt. #19's metoprolol present in the binder, E#2 stated that Pt. #19's metoprolol dose was due this morning at 9:00 AM; however, the dispensing machine was out of stock. When asked why Pt. #19's MAR showed that the metoprolol was already administered at 8:53 AM, E#2 stated that E#2 must have entered it as given when E#2 was administering Pt. #19's other morning medications. E#2 could not explain how the metoprolol could have been scanned in with the other morning medications prior to the metoprolol being available on the unit. E#2 stated, "I made a mistake ... it should be marked that it was not given."

6. Medication Dispensing Activity Logs and 8 patient records (Pts. #17-#24) from the 14th Floor BHU on 7/29/19, were reviewed on 7/29/19 and indicated that a RN (E#2) retrieved medications for 8 patients (Pts. #17-#24) from 7:53 AM to 8:16 AM, instead of 1 patient at a time. The MARs for these 8 patients indicated that these medications were administered from 8:26 AM to 8:39 AM (after all 8 patients' medications were retrieved from the dispensing machine).

7. Medication Dispensing Activity Logs and 27 patient records (Pts. #25-#51) from the 14th Floor BHU, on 6/9/19 and 7/7/19, were reviewed on 7/31/19 and indicated the following:

- On 6/9/19, RN (E#6) retrieved medications for 7 patients (Pts. #26-#32) from 7:55 AM to 8:00 AM, instead of one patient at a time. The MARs for these 7 patients indicated that these medications were administered from 8:26 AM to 8:38 AM (after all 7 patients' medications were retrieved from the dispensing machine).

- On 6/9/19, E#6 retrieved two medications for Pt. #25 at 1:29 PM and 3:37 PM. E#6 returned Pt. #25's medications to the dispensing machine at 5:41 PM, after retrieving and administering medications for 4 other patients (Pts. #29-#32) from approximately 1:30 PM to 5:38 PM.

- On 6/9/19, RN (E#5) retrieved medications for 9 patients (Pts. #42-#50) from 8:03 AM to 8:17AM, instead of one patient at a time. The MARs for these 9 patients indicated that these medications were administered from 8:23 AM to 8:39 AM (after all 9 patients' medications were retrieved from the dispensing machine).

- On 6/9/19, RN (E#5) retrieved risperidone (used to treat schizophrenia) for Pt. #51 at 6:40 PM. Pt. #51's MAR indicated that the risperidone was given at 6:03 PM (37 minutes before the medication was retrieved).

- On 7/7/19, RN (E#2) retrieved medications for 9 patients (Pts. #32-#40) from 8:32:AM to 8:43 AM, instead of one patient at a time. The MARs for these 9 patients indicated that these medications were administered from 9:02 AM to 9:21 AM (after all 9 patients' medications were retrieved from the dispensing machine).

- On 7/7/19, RN (E#2) retrieved lithium (used to treat depression) and benztropine (used to treat involuntary movements due to the side effects of certain psychiatric drugs) for Pt. #41 at 10:13 AM. Pt. #41's MAR indicated that the risperidone and benztropine were given at 9:10 AM (1 hour and 3 minutes before the medications were retrieved).

- On 7/7/19, RN (E#2) retrieved quetiapine (used to treat certain mental/mood conditions) for Pt. #41 at 2:48 PM. Pt. 41's MAR indicated that the quetiapine was given at 1:30 PM (1 hour and 18 minutes before the medication was retrieved).

8. An interview was conducted with the Registered Nurse (E#5) on 7/31/19, at approximately 9:10 AM. E#5 stated, "We're not allowed to retrieve more than one patient's medications at a time." E#5 stated that all medications are scanned during administration and stated that once a medication is scanned, it automatically documents that the medication was given at that time in the patient's MAR. When asked about the records on 6/9/19, indicating that medications were pulled by E#5 for multiple patients prior to the documented administration times and that a medication was documented as given before it was dispensed, E#5 stated "I don't recall what happened that day.

9. An interview was conducted with the 14th Floor Team Leader (E#7) on 7/31/19, at approximately 8:45 AM. E#7 stated that patient identification bands and medication barcodes are scanned with each administration. E#7 stated that only one patient's medications should be pulled at a time and should be administered prior to retrieving another patient's medications. E#7 stated that if a patient refuses a medication, the medication should be returned to the dispensing machine after finishing with that patient and should never be taken into another patient's room. E#7 stated that these protocols are in place to prevent potential medication errors. When informed of the observations on 7/29/19, E#7 stated, "It doesn't make sense how a medication could be scanned in if it wasn't available on the unit." In relation to the discrepancies noted in the records with medication retrieval and administration times, E#7 stated that she will have to talk to the nurses about it.