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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that patient rights were protected. This placed current, and future patients admitted to the Hospital's Behavioral Health Unit 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 care in a safe setting by identifying and removing ligature risks on the Adult Behavioral Health Unit (ABHU). See deficiency cited at A-144-A.

The immediate jeopardy was identified on 08/19/2020, due to the Hospital's failure to identify and remove ligature risks on the Adult Behavioral Health Unit (ABHU) and that patients were free from risk of causing self-harm/injury. This was identified on 08/19/2020 at 42 CFR 482.13, Patient Rights.

The IJ was announced on 08/20/2020 at 12:20 PM, during a meeting with the Chief Administrative Officer, Chief Medical Officer, Director of Nursing, Chief Operations Officer, System Director of Behavioral Health Unit, Vice-President of Care Transformation, Executive Director for Behavioral Health, and Chairman - Department of Psychiatry. The IJ was not removed by the survey exit date of 08/20/2020.

A. Based on observation, document review and interview it was determined that the Hospital failed to ensure care in a safe setting by identifying and removing ligature risks on the Adult Behavioral Health Unit (ABHU). This has the potential to affect the safety of the 17 psychiatric patients on census as of 08/19/2020 and any future psychiatric patients who become suicidal.

Findings include:

1. On 08/19/2020 between 9:00 AM - 11:00 AM, an observational tour of the - Adult Behavioral Health Unit (ABHU) was conducted. The following were observed during the tour:

- Eight (8) patient rooms with restraint-capable beds had four (4) steel rings attached on both sides of bed, to be used as attachment points for restraints; and two (2) bathroom doors with separated and protruding hinges.

2. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 08/13/19, 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..."

3. The Hospital policy titled, "Patient Rights and Responsibilities" dated 06/2020 was reviewed and included, " ...D. Patient have the right to be comfortable and safe ...2. To receive care in a safe setting ..."

4. On 08/19/2020 at approximately 10:10 AM, an interview was conducted with the Executive Director of the ABHU (E #3), who stated that, it is not safe to have patients in these identified ligature risk rooms. The last ligature risk assessment was done in January 2020. I am not sure why the staff did not identify these ligature risks during their environmental rounds.


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B. Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for elopement, the Hospital failed to ensure care in a safe setting by not following there elopement policy.

Findings include:

1. On 8/19/2020, Pt. # 1's clinical record was reviewed. Pt. #1 was admitted to the Hospital with a diagnosis of paranoid delusion. E #4's note dated 8/14/2020 indicated that Pt. #1 grabbed E #4's ID badge, opened the unit's exit door, and left through stairwell 11. The nurses note did not indicate that Dr. Elope (assistance for patient elopement) was called.

2. On 8/19/2020, the Hospital's policy titled, "Elopement from Inpatient Behavioral Units" (revised 2/2020) was reviewed and included, " ...III ... the inpatient psychiatric caregivers and leadership have established and agreed on guidelines for preventing elopement, practing (in the event of a successful elopement) ... V. Procedure ... 5. If it is suspected that a patient is missing from the unit: a. Extension 2333 is dialed, and a code Dr. Elope is called for the unit ..."

3. On 8/19/2020, the Hospital's policy titled, "Missing Patient/Patient Elopement" (revision date 1/18) was reviewed and included, "Purpose: To conduct an immediate search of the campus and return the patient to their room ... Once it has been identified that a patient is or may be missing from his ... patient floor, the Public Safety Department must be immediately notified (dial #29) on any in-house phone. Provide the Public Safety Dispatcher with the patient's name and as clear as a description as possible ... Upon receipt of the call, the Dispatcher will immediately notify all officers. A search of the premises inside and out will begin ..."

4. On 8/19/2020 at approximately 3:30 PM, a telephone interview was conducted with E #4 (Registered Nurse). E #4 stated, "I did not hear Dr. Elope was called." . E #4 stated that when a patient elopes, Dr. Elope (code for a patient elopement) is called via the overhead page. E #4 said, "I did not hear the code ... *0 is dialed to call for Dr. Elope. "

5. On 8/20/20 at approximately 9:15 AM, an interview was conducted with E #10 (Security Officer). E # 10 stated that when Pt. #1 eloped a code gray (security assistance for patients with behavioral problem) was called instead of the Dr. Elope (assistance for patient elopement). E #10 stated, "Dr. Elope should have been called ... We were not able to search the entire Hospital to look for (Pt. #1)."

6. On 8/20/2020 at approximately 10:20 AM, findings were discussed with E #11(Systems Director for Inpatient Behavioral Health) and E #12 (Systems Director Regulatory and Patient Safety). E #11 and E #12 agreed that the code Dr. Elope should be called for patient elopement. To call for Dr. Elope, E #11 stated that staff dials *0 (star zero).