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

A-0144 PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on observations, interviews, and document reviews, the facility failed to ensure a safe patient care environment in multiple areas throughout the facility. Specifically, the facility failed to ensure staff performed active rounding and monitoring of patients in accordance with facility policies, which resulted in a sentinel event (a patient safety event resulting in serious harm or death) (Patient #1). Additionally, the facility failed to ensure items that posed a safety risk to patients or others were not accessible to patients in two of two observations of the cafeteria. Furthermore, the facility failed to ensure ligature (an item used for tying or binding something, often referring to an item tied around the neck causing compression of the airway and even death) and environmental risk assessments were performed for the cafeteria, the gymnasium, and outdoor patient courtyards.

Based on observations, interviews, and document reviews, the facility failed to ensure a safe patient care environment in multiple areas throughout the facility. Specifically, the facility failed to ensure staff performed active rounding and monitoring of patients in accordance with facility policies, which resulted in a sentinel event (a patient safety event resulting in serious harm or death) (Patient #1). Additionally, the facility failed to ensure items that posed a safety risk to patients or others were not accessible to patients in two of two observations of the cafeteria. Furthermore, the facility failed to ensure ligature (an item used for tying or binding something, often referring to an item tied around the neck causing compression of the airway and even death) and environmental risk assessments were performed for the cafeteria, the gymnasium, and outdoor patient courtyards.

Findings include:

Facility policies:

The Unit Rules policy read, the purpose of this policy is to prevent staff on duty from being distracted by staff on break causing them to lose focus on patient care assignments. If a staff member is taking a break during a designated patient meal time in the cafeteria, staff may not be interacting with their peers who are still on shift and monitoring patients. These staff must be solely focused on the cafeteria environment, plastic ware (spork) counts, patient engagement, and patient communication. This is done via direct observation, focus on patients, and active rounding throughout the dining room area and food service line. Staff are to continually round "WALK" while in the dining area. In the event someone gets up the staff is to round until the patient returns. Staff observing patients while on duty in the cafeteria should not be eating, nor sitting and visiting with peers on break. The focus should be on the patients at all times. Utensils will be regulated by staff per the utensils protocol. Staff will perform active rounds around the cafeteria while the patients are eating.

The Staff Meal Breaks policy read, the purpose of this policy is to prevent staff on duty from being distracted by staff on break causing them to lose focus on patient care assignments. When staff are on their designated break they should take their break in one of the following locations: the staff break room, the Florence room, the outside dining room courtyard, or the back pergola. During non-unit meal times, staff are free to sit at any table in the dining room.

The Belongings & Contraband policy read, in order to maintain safety in patient areas, certain items will be classified as contraband. Contraband is defined as any item that is not approved by the facility and is deemed a potential threat to patients, or staff or is illegal. Contraband may include: items discovered in the possession of a patient on a unit or other secured area or any area of the facility to which the patients have access; any object whose purpose is to inflict serious injury, regardless of the manner in which it is discovered; any neutral object that could be used to or has been modified for the purpose of inflicting injury to self or others.

When distributing and monitoring the utensils provided to patients during meal time, staff are to stand next to the utensils and hand one utensil to each patient and document how many utensils each patient has. Staff will document the distribution of utensils using the meal monitoring sheet. Whenever patient(s) return to the cafeteria line or soda fountain area, a staff member is to monitor the patient to ensure they do not grab additional utensils. If they require additional utensils, their initial utensil must be accounted for and turned in prior to getting new utensils.

The Environmental Rounds policy read, the facility will conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks. As part of an ongoing environment of care program, the Director of Plant Operations or designee shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety, security, fire safety, hazardous conditions, exposure to hazardous materials and wastes, medical equipment, utilities, and staff knowledge.

The Kitchen Security policy read, the purpose of this policy is to ensure a safe environment is maintained for patients and staff. Kitchen doors are closed and locked at all times. All sharps are located in an area that can be locked. All sharps are counted daily at closing. The supervisor is notified immediately if all knives are not present.

The Patient Observation Levels and Management policy read, the purpose of the policy is to ensure patient safety and provide a process for observing and documenting patient location and behavior. Observation of the patient should be conducted in a thorough manner in order to ascertain that the patient is safe. Observation should be visual and include monitoring of the patient to establish patient safety. Observation levels go beyond the order of every 15 minutes, five minutes, or 1:1 observations to maintain patient and milieu safety. Patient observation management includes patient activities, positioning, and active rounding at all times. Be aware of times when focus can be diverted such as during patient meal time. Patient observation management includes active rounding at all times. Active rounding is the act of continually rounding through all patient care spaces. During rounding, staff should be continually monitoring patient safety, the location of the patient, and the patient's behavior.

The Sentinel Event policy read, a sentinel event is an unexpected occurrence (adverse event) resulting in an unanticipated death, serious physical or psychological injury, or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition.

References:

The Risk Management Plan read, the purpose of risk management is to enhance the quality of patient care by preventing and/or decreasing the frequency and severity of undesirable or adverse patient care occurrences. The risk management program is designed to identify areas that may represent actual or potential sources of patient injury, provide a physical environment free of hazards, and manage staff activities to reduce the risk of human injury. The goals and objectives of the plan are to support, maintain, and enhance the quality of care delivered by identification and assessment of general areas of actual or potential risk in the clinical aspects of the delivery of patient care and safety. The risk manager is responsible to supervise and maintain a risk-assessment program that evaluates the impact on patient care and safety of the buildings, grounds, occupants, and internal physical systems. Conduct and document facility-wide surveys on at least a semiannual basis to identify environmental hazards and unsafe practices.

1. The facility failed to ensure staff actively rounded and monitored patients according to facility policies to maintain patient safety. This failure resulted in a sentinel event leading to significant patient harm.

A. Review of surveillance videos recorded on the day of 9/7/23 revealed the following:

i. At 11:30 a.m., the video revealed the entrance door to the cafeteria. To the left of the entrance door, there was a tray return pass-through window, which led from the cafeteria into the kitchen. A food service line area was located to the right of the pass-through window, which was where patients were served food, beverages, and condiments. The food service line area was partially partitioned by a wall that separated the food service line from the dining hall area where patients ate their meals.

ii. At 11:33 a.m., mental health technician (MHT) #2 escorted nine patients to the cafeteria for lunch. At this time, Patient #1 was observed in the food service line in the cafeteria.

iii. At 11:36 a.m., Patient #1 exited the food service line with his lunch on a food tray. Patient #1 then walked to a dining table in the dining hall, sat down with the tray, and began to eat.

iv. At 11:37 a.m., MHT #2 walked into the dining hall area of the cafeteria and sat down at a dining table located near where the patients eating lunch were seated.

v. At 11:40 a.m., MHT #3 entered the cafeteria and sat down in a chair at the dining table where MHT #2 was seated.

vi. From 11:46 a.m. to 11:48 a.m., both MHT #2 and MHT #3 stood up from the dining table and walked into the food service line. Surveillance video showed MHT #2 ordered food and MHT #3 engaged in conversation with two staff members. Both MHT #2 and MHT #3 had their backs turned away from the patients in the dining area while in the food service line area. During this time, no additional MHT staff were in the dining area actively rounding on the patients.

vii. At 11:47 a.m., Patient #1 stood up from the dining table, carried the items on his food tray over to a garbage bin, and discarded the contents of the tray into the garbage bin. Patient #1 then walked to the tray return pass-through window, where he slid his food tray through the pass-through window from the cafeteria into the kitchen. Next, Patient #1 bent forward, looked into the tray return pass-through window, stood back up, and looked around the dining hall and the food service line. The patient then bent forward again, entered the pass-through window, and gained access to the soiled utensil cleaning area of the kitchen.

viii. At 11:49 a.m., two minutes after Patient #1 entered the kitchen through the pass-through window, the kitchen manager was seen hurriedly exiting the kitchen. The video further revealed both MHT #2 and MHT #3 stood up and looked in the direction of where the kitchen manager was. The kitchen manager was then seen rushing back into the kitchen while MHT #2 was observed talking into a two-way radio. During this time, MHT #3 followed the kitchen manager back into the kitchen. At 11:50 a.m., staff were seen arriving in the cafeteria with the code cart (a wheeled cart filled with emergency medical supplies, medications, and equipment).

The surveillance video review was in contrast to the Unit Rules policy which instructed that staff must be solely focused on the cafeteria environment, patient engagement, and patient communication, via direct observation. Staff was to continually round "WALK" while in the dining area. In the event someone got up, staff was to round until the patient returned.

B. Review of Patient #1's medical record revealed on 9/7/23 at 11:49 a.m., a code blue (a medical emergency event) was called in the cafeteria kitchen, and emergency medical assistance was needed for Patient #1.

i. The Code Blue and the Medical Response Code forms in Patient #1's medical record revealed after Patient #1 was in the soiled dish and utensil area of the kitchen, he acquired a large food preparation knife and inflicted life-threatening injuries to his throat and abdomen with the knife. The patient was transported by emergency medical services (EMS) to the emergency department of an acute care hospital.

C. On 9/12/23 at 1:25 p.m., an interview was conducted with the director of risk management (Director) #1. Director #1 stated after the event occurred, Patient #1 was sent to the emergency department where he succumbed to his injuries and died.

Additional interviews with staff revealed staff were not re-trained after the sentinel event on how to conduct observations of patients in the cafeteria.

i. On 9/11/23 at 6:08 p.m., an interview was conducted with MHT #4. MHT #4 stated during patient meal times in the cafeteria, she performed patient observations and was also responsible for monitoring patients. MHT #4 stated she had not been informed that staff should not have been seated when patient observations were performed. MHT #4 further stated she had not been instructed that MHTs were supposed to walk around the cafeteria and visually monitor patients while in the cafeteria.

ii. On 9/12/23 at 12:19 p.m., an interview was conducted with MHT #2. MHT #2 stated MHTs were responsible for conducting and documenting patient observations while on inpatient units and while in the cafeteria. MHT #2 stated patient observations were performed to ensure patients were safe at all times.

MHT #2 stated she usually sat down at a table near the patients during patient meal times in the cafeteria. MHT #2 stated after the sentinel event with Patient #1, she decided to stop sitting during patient meals in the cafeteria. MHT #2 stated the sentinel event with Patient #1 made her realize she should continually walk around and monitor patients to ensure patients remained safe. MHT #2 stated prior to the sentinel event with Patient #1, she had not been informed that staff was required to constantly walk around and visually monitor patients when in the cafeteria. MHT #2 further stated following the sentinel event there was no communication or education provided from the facility clarifying or reviewing how patient observations were to be performed.

iii. On 9/11/23 at 5:09 p.m., an interview was conducted with the director of risk management (Director) #1. Director #1 stated after the sentinel event on 9/7/23, the facility modified the width of the opening for the tray return pass-through window. Director #1 stated prior to the event it had not been identified that the opening of the pass-through window was wide enough for a patient to fit through.

iv. On 9/12/23 at 12:54 p.m., an additional interview was conducted with Director #1. Director #1 stated after the sentinel event occurred, computer-based education was assigned to all staff at the facility. Director #1 stated the computer-based training module focused on patient suicide risk assessments and levels of precautions. Director #1 explained in addition to the computer-based training, additional training would be done during the week of 9/18/23 (eleven days after the event with Patient #1 occurred).

Upon review of the computer-based course content assigned to the staff, there was no evidence staff were provided education on the expectations when conducting observations in the cafeteria.

D. On 9/11/23 from 5:20 p.m. to 5:40 p.m., an observation of the cafeteria was conducted.

The observation revealed seven patients seated at dining tables eating dinner. At an adjacent table, an MHT was seated while he performed patient observations. The MHT then began engaging in conversation with a peer who had approached the table he was seated at.

During the observation, the director of clinical services (Director) #5 was interviewed. Director #5 stated MHTs frequently sat at a dining table while monitoring patients during patient meal times.

2. The facility failed to ensure contraband (items that posed a potential safety risk and could be used to inflict patient harm) were not accessible to patients.

A. Observations of the cafeteria food service line area revealed staff failed to monitor items that posed a potential safety risk to patients.

i. On 9/12/23 at 11:38 a.m., observations of the cafeteria revealed two wastebaskets lined with plastic trash bags in the food service area. One of the wastebaskets also contained multiple used eating utensils (sporks). During the observation, patients were present in the food service line area and the dining hall area of the cafeteria. The items in the two wastebaskets were not monitored by staff.

ii. Additional observations conducted on 9/13/23 in the cafeteria revealed sporks were not monitored. At 7:58 a.m., observations revealed patients were in the cafeteria for breakfast. Two patients were observed getting food from the food service area. After both patients were handed their food, they each retrieved an unused spork from a round black container located at the end of the food service line. The two patients were not being observed by staff.

From 8:07 a.m. to 8:12 a.m., observations revealed patients were not monitored by staff when they discarded their sporks. Additionally, staff were not observed documenting which patients had sporks and which patients had returned or disposed of their sporks.

The observations were in contrast to the Belongings & Contraband policy, which instructed staff to stand next to the utensils, hand one utensil to each patient, and document how many utensils each patient had. The policy also instructed staff to monitor the patients who returned to the cafeteria line or soda fountain area to ensure they did not grab additional utensils.

B. Interviews with staff confirmed the facility failed to ensure the safety of patients from items in the cafeteria that posed a potential safety risk and could have been used to inflict patient harm.

i. On 9/12/23 at 12:19 p.m., an interview was conducted with MHT #2. MHT #2 stated contraband was defined as any object a patient could use to self-harm or cause harm to others. MHT #2 stated she had not been instructed to monitor the wastebaskets or the plastic trash bags while in the cafeteria with patients. MHT #2 stated wastebaskets and plastic trash bags were not present on inpatient units since both items could be used by a patient to self-harm.

ii. On 9/13/23 at 1:37 p.m., an interview was conducted with MHT #3. MHT #3 stated during meal times in the cafeteria, staff was expected to physically hand one spork to the patient. MHT #3 stated she did not track which patients were given a spork and if the spork was later visualized prior to being discarded. MHT #3 stated she had not been provided education regarding how to monitor and reconcile spork distribution to patients while in the cafeteria. MHT #3 stated sporks were considered contraband since patients could use a spork to self-harm.

iii. On 9/13/23 at 4:42 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated MHTs were supposed to document on a meal monitoring sheet (referenced in the Belongings & Contraband policy) which patients were provided a spork and also which patients discarded or returned their spork. However, CNO #6 stated the facility did not enforce the use of the meal monitoring sheet to document the distribution of utensils during patient meal times. CNO #6 stated the purpose of the meal monitoring sheet was to ensure patients did not keep their spork after meals. CNO #6 stated patients could modify a spork and potentially use it to harm themselves or others.

3. The facility failed to perform ligature and environmental risk assessments within all areas of the facility to ensure the safety and well-being of patients and mitigate patient safety risks.

a. The Safety Ligature Risk Assessment, provided by the facility on 9/14/23 at 10:37 a.m., was reviewed and revealed the facility had not performed a facility-wide ligature and environmental risk assessment. According to the Safety Ligature Risk Assessment, the assessment was completed on 2/20/23. The following locations were assessed for actual or potential safety risks: patient bedrooms, patient lobby and intake bathrooms, hallways, the lobby, the seclusion room, assessment rooms, patient dayrooms, patient group rooms, and patient activity rooms. The assessment indicated what actions were implemented in the observed areas to mitigate ligature risks.

Further review of the Safety Ligature Risk Assessment revealed the following areas accessible to patients had not been assessed for ligature and environmental risks: the cafeteria, the gym, and the outdoor courtyards.

This was in contrast to the Risk Management Plan which read, the facility would conduct facility-wide assessments to identify actual or potential patient safety risks, environmental risks, potential hazards, and unsafe practices to mitigate potential danger and risk of human injury.

b. Observations of the cafeteria conducted on 9/12/23 and on 9/13/23 revealed two wastebaskets lined with plastic trash bags in the food service area. One of the wastebaskets also contained multiple used eating utensils (sporks).

The observation was in contrast with the Safety Ligature Risk Assessment, which listed plastic trash liners as items not allowed in the patient care areas included in the assessment (patient bedrooms, patient lobby and intake bathrooms, hallways, the lobby, the seclusion room, assessment rooms, patient day rooms, patient group rooms, and patient activity rooms).

c. On 9/18/23 at 10:35 a.m. an interview was conducted with the director of risk management (Director) #1. Director #1 stated ligature and environmental risk assessments were performed yearly. Director #1 further stated ligature and environmental risk assessments were performed for all patient care areas and throughout the entire facility.

During the interview, Director #1 reviewed the Safety Ligature Risk Assessment provided to surveyors on 9/14/23. After Director #1 reviewed the Safety Ligature Risk Assessment she verified that the cafeteria, gym, and outdoor courtyards had not been assessed during the ligature and environmental risk assessment performed on 2/20/23.

Director #1 further stated given the circumstances of the sentinel event with Patient #1 on 9/7/23, ligature and environmental risk assessments should have been and needed to be conducted in all areas accessible to patients to mitigate potential danger and risk of patient harm.