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Based on observation, interview and record review, the facility failed to ensure the conditions of participation for Patient' Rights were met as evidence by the facility failing to:

1. Ensure patient in the Emergency Room (ED) have the right to be safe when seeking treatment for seven (Patients 13, 25, 26, 27, 28, 29, and 30) of seven patients and also their staff. (Refer A 129).

2. Ensure the physician signed the patient informed consent (an explanation of a medical procedure or treatment before the patient agrees to it) form for a peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) line to indicate the procedure and risk and benefits were discussed with two (Patient 2 and 3) of three sampled patients. (Refer A 131).

3. Conduct ongoing monitoring and identifying of hazards in the Mental Health unit (specializing in the treatment of patients with mental disorders) for one of eight patients (Patient 4), who had the diagnosis of suicidal ideation (thinking about or planning suicide). (Refer A 144).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure patient in the Emergency Room (ED) have the right to be safe when seeking treatment for seven (Patients 13, 25, 26, 27, 28, 29, and 30) of seven patients and also their staff by:

1. Not performing a search and safety check as indicated by their policy and procedure (P&P), "Search and Safety Check," on Patient 1.
2. Not indicating a procedure to discontinue CODE GREY (a situation where a person becomes combative and requires the presence of the security team).
3. Not recognizing the suspicious behavior of a patient to warrant a search and safety check.

This deficient practice resulted in Patient 1 stabbing Physician (MD) 1 , Registered Nurse (RN) 1 and 2. There was also the potential for bodily harm or death.

On June 8, 2022, at 4:50 p.m., the survey team called an immedicate jeopardy (IJ) situation in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), RN Director (RND), Director of Pharmacy (DOP), and Director of Mental Health (DMH) and were informed of the IJ situation regarding the failure to ensure the safety of their patients and staff which caused Patient 1 stabbed three staff members (one physician (MD1) and two registered nurses (RN 1 and RN2) to be on 5/27/2022.

On June 9, 2002, at 3:55 p.m., IJ situation was removed after verifying an acceptable IJ removal plan. The removal plan indicated a process to ensure the safety of the facility's patients and staff.

The acceptable IJ removal plan addressed the following:
1. Dedicated public safety officers were assigned to the ED.
2. Public safety officers preformed safety screening on all patients entering the ED.
3. Safety check and CODE GREY policies and procedures were revised.
4. All facility staff were informed of changes to policies and procedures.

Findings:

A review of Patient 1's triage report, dated 6/3/2022 at 3:26 p.m. it indicated Patient 1 refused to answer any questions, stated, "I think I got poisoned," and was walking around into the, "Other rooms," and uncooperative.

An interview on 6/8/2022, at 11:03 a.m., Patient Access Representative (PAR 1) stated Patient 1 appeared to be, "Sweating bullet and seemed to be on drugs," and twice Patient 1 kept tried to enter the emergency department (ED) when the locked doors opened as someone was exiting.

An interview on 6/10/2022, at 2:10 p.m., Security Guard (SG) 1, stated he encountered Patient 1 when he arrived to the facility. SG 1 stated Patient 1 appeared to be, "Acting strange," sweaty, pacing, and "On drug." SG1 stated he responded to the Code Grey alert in which Patient 1 had to be restrained to receive medication to calm Patient 1 down and after that he was dismissed by MD1. SG1 stated a few minutes later he found MD1, RN1, and RN2 with stab wounds and Patient 1 holding a pocketknife. SG1 stated he was never asked by the clinical staff to search the patient. SG1 had warned staff not to get too close to Patient 1 after being dismissed from the ER.

An interview on 6/8/2022, 10:38 a.m., the Director of Security (DOS) stated he reviewed the security camera video of the incident with Patient 1 and corroborated it with facility staff interviews. He stated when Patient 1 arrived to facility on 6/3/2022, Patient 1 was pacing, "Appeared to be on drugs and jittery." After Patient 1 was brought into the ER he becomes uncooperative with the facility staff. A "Code Gray" (a situation where a person becomes combative and requires the presence of the security team) was initiated by the ER staff, to desolate the situation with Patient 1. The security team arrived to assist the nursing staff to restrain Patient 1 to sedate him with medication. After few minutes the security team proceeds to leave the ER and Patient 1 stabbed MD1, RN1, and RN2 with a pocketknife. The security team was able to contain Patient 1 in a room until the local police department arrived.

A concurrent interview and record review on 6/8/2022, 10:55 a.m., with the DOS, "Search and Safety Check in the Emergency Department," P&P, dated 1/22/2019, was reviewed. The P&P indicated the patient will be searched when the patient presents in an alternated mental state that leads the nurses or other staff to believe he is under the influence of an illegal substance. DOS stated the security team would search the patient by direction of the clinical staff. DOS stated that Patient 1 was not searched on 6/3/2022.

A concurrent interview and record review on 6/8/2022, 1:00 p.m., with the CNO, "Combative Person (Code Grey) P&P dated 2/2020, was reviewed. The P&P indicated Code Grey is a situation in which a person has lost all rational thinking and is now a threat to himself or others which may result to violent and/or immediate dangerous event, requiring a requiring a response by the facility security team. The P&P did not indicate a procedure to re-assess and ensure safety at the end of a Code Grey situation before dismissing the security team. CNO stated the P&P does not indicate a process to end the Code Grey.

A concurrent interview and record review on 6/8/2022, 1:12 p.m., with Director of Nursing (RND), the facility's ED patient log, dated 6/3/2022, was reviewed. The ED patient log indicated Patient 13, 25, 26, 27, 28, 29, and 30 were in the emergency department on the day of Patient 1's incident. RND stated the seven patients were evacuated out of the ER into other units of the facility to continue their care and treatment.

Based on interview and record review, the facility failed to ensure the patient informed consent (explanation of a medical procedure before the patient agrees to it) form for a peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) was signed by the physician to indicate the procedure and risk and benefits were discussed with two (Patient 2 and 3) of three sampled patients.

This deficient practice had the potential for the patient not to receive relevant infomration to make an informed decision for a medical procedure.

Findings:

1. A review of the Patient 2's "History and Physical" (H&P), dated 5/17/2022, it indicated, Patient 2 was admitted to the facility for chronic obstructive pulmonary disease (COPD - chronic infllammatory lung disease) with exacerbation (a worsening of inflammation in the lungs).

A review of Patient 2's physician orders, dated 5/17/2022, indicated, Patient 2 was ordered to have a peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart).

A review Patient 2's "Consent" for the PICC, dated 5/17/2022, indicated the physician did not sign, date, or time the form

2. A review of the Patient 3's H&P, dated 6/7/2022, it indicated, Patient 3 was admitted to the facility for Addisonian crisis (a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium).

A review of Patient 3's physician orders, dated 6/7/2022, indicated, Patient 3 was ordered to have a PICC line.

A review Patient 3's "Consent" for PICC, dated 6/7/2022, indicated the physician did not sign, date, or time the form.

During an interview on 6/09/2022, at 11:00 a.m., the Intensivist Medicine Doctor (IMD) stated the Patient's 3 PICC consent form should have been signed to indicate who placed the PICC line and that the procedure and risk and benefits were discussed with the patient. IMD stated Patient 3's PICC consent form is incomplete.

A review of the facility's P&P titled, "Consent, Informed," dated 2/3/2020, it indicated, the procedure for obtaining informed consent from the patient included: "The physician obtaining consent signs, dates, and times in appropriate location," and "All the blanks on the consent form are completely filled out" on the form.

Based on observations, interviews, and record review, the facility failed to provide a safe environment in the mental health unit (MHU [specializing in the treatment of patients with mental disorders]) by not identifying and monitoring for environmental safety risks in the MHU for one of eight patients (Patient 4), who had the diagnosis of suicidal ideation (thinking about or planning suicide).

The deficient practice had the potential to result in one patient with suicidal ideation to have access to objects that may be used to cause physical harm, injury, or death to self, other patients, staff, and visitors.

Findings:

During a concurrent observation and interview on 6/9/2022, at 11:53 a.m., with Director of the MHU (DMH), in the MHU television and activity room, the television cords encased, and the refrigerator power cord was observed exposed and accessible. DMH stated, the television cords were encased to prevent patients from causing harm to themselves or others and that the refrigerator cord should not be exposed because the patient could self-inflict harm with the cord.

An interview on 6/9/2022, at 11:55 a.m., MHU Charge RN (RN5), stated that patients with a diagnosis of suicidal ideation are at a greater risk for harming themselves in the MHU and require routine monitoring.

A review of Patient 4's "History and Physical" (H&P), dated 6/2/2022, it indicated Patient 4 was admitted to the MHU for suicidal ideation.

During a concurrent interview and record view, on 6/9/2022 , at 3:00 p.m. with DMH, MHU Charge Nurse Checklist, dated 6/9/2022, was reviewed. The MHU Charge Nurse Checklist indicated safety rounds in all patient rooms and areas to ensure safety twice a day. DMH stated that the refrigerator cord finding in the television and activity room should have been identified as a risk to the patients.

A review of facility's "Patient Safety Plan," dated 2/9/2022, it indicated facility staff will proactively identify hazards and risks and mitigate conditions.