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Based on observations, interview, and record review, the hospital failed to ensure the Governing Body functioned effectively and held the ultimate responsibility for the hospital's compliance, not only with the specific standards of the Governing Body Condition of Participation (CoP), but also with all of the CoPs for the provision of services, as evidenced by:

1. Failed to ensure contracted services were evaluated to ensure the contracted service was provided in a safe and effective manner. (Cross Reference A-084, A-085).

2. Failed to ensure that the facility had written policies and procedures for appraisal and initial treatment of patients experiencing a medical emergency. (Cross Reference A-093).

3. Failed to keep one patient (Patient 1), who had recently attempted suicide, safe and free from self-harm. (Cross Reference A -115, A-144).

4. Failed to communicate clearly to staff the assigned duties for the AM shift on 11/6/23 and ensure those duties were carried out. (Cross Reference A-385, A-392).

5. Failed to maintain the hospital facilities and equipment, to meet the needs of all patients, and adequately ensure life safety from fire requirements were met.
(Cross Reference A-0700, A-0701).
Adequately ensure life safety from fire requirements were met.
(Cross Reference E004, E0025, K920, K781, and K926).

6. Failed to demonstrate an individual was qualified through education, training, experience or certification in infection prevention and control and was appointed by the governing body. (Cross Reference A-748).

7. Failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. (Cross Reference A-263, A-273).

The cumulative effects of these systemic problems resulted in the hospital's inability to provide Nursing Services in a safe and effective manner, in accordance with the statutorily-mandated Conditions of Participation for Nursing Services; the hospital's inability to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program, in accordance with the statutorily-mandated Conditions of Participation for Quality Assurance Performance Improvement; the hospital's inability to provide a safe environment, in accordance with statutorily-mandated Condition of Participation Physical Environment; and, the hospital's inability to provide well-organized Patient Rights, with the statutorily-mandated Conditions of Participation Patient Rights Services.

Based on interview, and administrative record review, the hospital failed to ensure contracted services were evaluated to ensure the contracted service was provided in a safe and effective manner. The hospital did not implement a Quality Assessment and Performance Improvement program (QAPI), to ensure services, furnished under contract, were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. This failure could result in services performed under contract to not be provided in a safe and effective manner.

Findings:

During a concurrent interview and document review on 11/15/23 at 9:45 a.m., with Director B and Administrative Staff J, the vendor contract list was requested and provided. Review of the untitled vendor contract list not dated indicted seven Contract Numbers. The vendor contract list did not provide the delineation of contractor responsibility.
Administrative Staff J concurred the vendor contract list was incomplete as the vendor contract list did not contain the names of contracts Administrative Staff J oversees (the landscape company, ice machine maintenance, vector maintenance).

Review of the second page of the vendor contract list provided indicated seven Contract Numbers. The seven Contract Numbers were the same Contract Numbers on page one. Page two documented the contract review process for the seven Contract Numbers. Page two, not dated, did not include the name/title of the contracts Administrative Staff J oversees (the landscape company, ice machine maintenance, vector maintenance).

Review of the policy titled "Quality Assurance/Performance Improvement Plan 2022-2023", last revised 1/27/22, indicated "...Policy Summary/Intent: To develop, implement, and maintain an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program...C. Collecting Data On Performance. 1. Scope of Data Collection At a minimum, the organization will collect and analyze data...Performance improvement priorities identified by leaders...Adverse patient events...Behavior management and treatment...Medication variances...Patient Safety...Staff opinions and perceptions related to patient and staff safely..."
Note: The QAPI Plan did not include the hospital had a mechanism to evaluate the quality of each contracted service.

Based on interview and document review, the hospital failed to maintain the list of all contracted services to include the scope and nature of services provided. This failure could result in services performed under a contract to be provided in a safe and effective manner.

Findings:

During a concurrent interview and document review on 11/15/23 at 9:45 a.m., with Director B and Administrative Staff J, the vendor contract list was requested and provided. Review of the untitled vendor contract list not dated indicted seven Contract Numbers. The vendor contract list did not provide the delineation of contractor responsibility.
Administrative Staff J concurred the vendor contract list was incomplete as the vendor contract list did not contain the names of contracts Administrative Staff J oversees (the landscape company, ice machine maintenance, vector maintenance).

Review of the policy titled "STANDARD POLICY: CONTRACT PROCESSING", last revised 2/2/23 indicated "...A. All nonphysician Contracts are processed within the contract management program by the corporate shared services contact management team & corporate sourcing team... B. All physician Contracts are processed within the contract management program...For a current comprehensive list, contact the AH System Governance Office..."

Based on observation, interview, and document review, the facility's Governing Body did not ensure that the facility had written policies and procedures for appraisal and initial treatment of patients experiencing a medical emergency when:

1. Nurses were not trained consistently on the initiation of Basic Life Support (BLS);

2. The facility had not implemented an education training and return demonstration for mock emergency management and code blue drills.

3. Emergency oxygen equipment had not been evaluated for intended use; and

These failures had the potential to result in the delivery of unsafe patient care due to inexperienced and untrained nurses in the event a patient became unstable on one of the four units and needed to receive emergency care 24 hours per day 7 days per week.

Findings:

1. a. During a concurrent observation, interview and document review, on 11/15/23 at 11:15 a.m., Licensed Staff L did not demonstrate or verbalize understanding of the proper placement of oxygen tubing to the oxygen cylinder. Licensed Staff L stated there had not been education or mock emergency training other than what she received during the initial BLS certification.

b. During a concurrent observation, interview and document review, on 11/15/23 at 11:15 a.m., Licensed Staff L did not demonstrate or verbalize understanding of the proper placement of the pocket mask and the pediatric manual resuscitator. Licensed Staff L stated she would use the pocket mask because the pediatric manual resuscitator mask did not provide a seal and "it was a little flat." Licensed Staff L and Administrative Staff K confirmed there had been no standardization of emergency equipment needed.

2. During an interview on 11/15/23 at 11:20 a.m., Administrative Staff K stated the hospital did not have a emergency service committee and did not have a training schedule to conduct random emergency drills (mock code blue) for each shift on each unit and no mock code blue drills had been conducted for over one year.

3. During a concurrent interview and document review on 11/15/23 at 10:05 a.m., Director B concurred the hospital did not have a emergency service committee to evaluate hospital emergency policies and procedures addressing emergency care needs and equipment for the patient population.

Review of the policy and procedure titled "FACILITY POLICY AND PROCEDURE: MEDICAL EMERGENCY MANAGEMENT/CODE BLUE" last revised 3/23/20 indicated "POLICY SUMMARY/INTENT...To provide a safe environment for managing emergency situations within the hospital when an individual is discovered in an unresponsive state or has a medical emergency not within the capability and or capacity of the hospital to treat...The hospital conforms to the American Heart Association recommendations for adult and pediatric cardiopulmonary resuscitation in Basic Life Support...Initiate BLS interventions on all inpatients and outpatients as needed...Initiate CPR as needed. If AED is used, follow directions on the AED as provided by the manufacturer..."

During a concurrent interview and document review on 11/15/23 at 10:05 a.m., Director B concurred the policy titled "FACILITY POLICY AND PROCEDURE: MEDICAL EMERGENCY MANAGEMENT/CODE BLUE" last revised 3/23/20 had not been reviewed or revised since 3/23/20.

Based on observation, interviews, clinical record review, facility document review, and videography evidence review: 1.a. The facility failed to keep one patient (Patient 1), who had recently attempted suicide, safe and free from self-harm when Patient 1 created a ligature (item used for tying/binding something tightly) from her a brassiere (bra) and utilized it to hang herself from her bedroom door, resulting in her death; 1.b. Staff (including nurses and technicians) walked past Patient 1's door (that was partially open with the bra visible from the hall) multiple times, but did not appear to notice the ligature; 1.c. Facility staff did not perform all required safety monitoring checks (visual check of patients done every 15 minutes to ensure their whereabouts and safety; also known as rounding) on Patient 1 on the day of her hanging from 7:23 a.m. to 7:57 a.m. (34 minute gap) and at 8 a.m., 8:15 a.m. and 8:30 a.m. (representing the time immediately prior to, and following Patient 1's hanging); 1.d. Staff did not document safety checks accurately at 8:45 a.m. and 9 a.m. (the time prior to staff discovery of Patient 1's body); 1.e. The facility did not ensure adequate staffing when Unit 2 (location where Patient 1 resided) did not have a sitter (designated staff member providing one-to-one patient supervision [one patient for one staff]) for Patient 2, during the timeframe Patient 1 hanged herself. This caused confusion regarding what specific staff was assigned to, and responsible for the safety monitoring, at a time when Unit 2 had high patient acuity (illness severity level; patient classification system designed to guide allocation of nursing staff); 1.f. Licensed nurses did not ensure Mental Health Technicians (MHT's; staff providing direct and indirect care to patients under the direction of a registered nurse [RN]) performed routine safety checks and 2. Staff did not perform all required safety checks for Patient 3, a minor diagnosed with depression, after the death of Patient 1.

These failures resulted in Patient 1 hanging herself to death in her room and not being found by staff for over one hour, and created potential for an unsafe environment for Patient 3 and other patients as risk for self harm (Cross Reference to A-0144).

The cumulative effect of these systemic problems resulted in the facility denying patients their right to receive care in a safe setting.

Based on observation, interviews, clinical record review, facility document review, and videography evidence review: 1.a. The facility failed to keep one patient (Patient 1), who had recently attempted suicide, safe and free from self-harm when Patient 1 created a ligature (item used for tying/binding something tightly) from her a brassiere (bra) and utilized it to hang herself from her bedroom door, resulting in her death; 1.b. Staff (including nurses and technicians) walked past Patient 1's door (that was partially open with the bra visible from the hall) multiple times, but did not appear to notice the ligature; 1.c. Facility staff did not perform all required safety monitoring checks (visual check of patients done every 15 minutes to ensure their whereabouts and safety; also known as rounding) on Patient 1 on the day of her hanging from 7:23 a.m. to 7:57 a.m. (34 minute gap) and at 8 a.m., 8:15 a.m. and 8:30 a.m. (representing the time immediately prior to, and following Patient 1's hanging); 1.d. Staff did not document safety checks accurately at 8:45 a.m. and 9 a.m. (the time prior to staff discovery of Patient 1's body); 1.e. The facility did not ensure adequate staffing when Unit 2 (location where Patient 1 resided) did not have a sitter (designated staff member providing one-to-one patient supervision [one patient for one staff]) for Patient 2, during the timeframe Patient 1 hanged herself. This caused confusion regarding what specific staff was assigned to, and responsible for the safety monitoring, at a time when Unit 2 had high patient acuity (illness severity level; patient classification system designed to guide allocation of nursing staff); 1.f. Licensed nurses did not ensure Mental Health Technicians (MHT's; staff providing direct and indirect care to patients under the direction of a registered nurse [RN]) performed routine safety checks and 2. Staff did not perform all required safety checks for Patient 3, a minor diagnosed with depression, after the death of Patient 1.

These cumulative failures resulted in Patient 1 hanging herself to death in her room and not being found by staff for over one hour, and created potential for an unsafe environment for Patient 3 and other patients at risk for self harm.

Findings:

1) During a tour of Unit 2 with the DON (Director of Nursing) on 11/13/2023 at 2:15 p.m., rooms 210 (Patient 1's room) and 211 were empty. The beds had sheets and blankets, but no pillows. The bathroom door was slanted (to mitigate ligature risk). The unit contained two Day Rooms (rooms utilized for recreation, social interactions, and/or group activities) and a patio (for supervised patient use).

Review of Patient 1's medical record revealed a psychiatric evaluation, written by Doctor of Nursing Practice (DNP) M, that indicated she was admitted to the facility on 10/30/2023 under a 5150 hold (California Welfare and Institutions Code that allows for an involuntary 72-hour hold when a person is a danger to themselves or others) for, "danger to self." DNP M documented Patient 1 had no known psychiatric history, this was her first psychiatric hospitalization, and she would have further psychiatric evaluation and stabilization at the facility. The evaluation indicated Patient 1 was placed on a 5150 hold for danger to self due to suicide attempt by strangulation on 10/23/2023 (seven days prior to admission at the facility). The evaluation indicated, "She attempted suicide by using the straps of a bag to asphyxiate herself.... She reported that she was desperate to end her life... patient reports feeling depressed and stressed out due to (family issues)...." DNP M diagnosed Patient 1 with "MDD (major depressive disorder), severe (Major depressive disorder, single episode, severe without psychotic (delusions-false belief [idea that a person or object is trying to hurt you] and hallucinations-a sensory perception [hearing voices] features..".

Review of Patient 1's medical record revealed a nurse's progress note written on 11/5/2023 at 9:40 p.m. (the evening prior to her death) that indicated, "Maintained Q15 (every 15) min (minute) safety checks for safety and facility protocol... Patient appears to be restless, anxious. She was sitting in her room crying for 2 hours. Appears to be paranoid with staff and does not have any insight of her condition. she wanted to talk on the phone with family... Patient finally dialed someone and talked on the phone. this helped relived (sic) her anxiety and tension. She narrated, 'get me out of here.. I am not crazy'..."

During an interview and concurrent viewing of the surveillance camera footage (camera located outside Patient 1's room, allowing partial visualization through Patient 1's partially-open door) on 11/14/23 at 10:15 a.m., the DON and Director B viewed the video, described events, and identified the staff present during the incident. The camera footage was downloaded into three sections: Section #1 was from approximately 8 a.m. to 8:29 a.m., #2 was from approximately 8:30 a.m. to 9:24 a.m., and #3 was from approximately 8:30 a.m. to 9:24 a.m. The video revealed at approximately: 8 a.m., Patient 1 was lying on the floor next to her bed; 8:06 a.m., Patient 1 gets up off the floor with what appears to be a bra on her head and walked out of camera view; 8:09 a.m. Patient 1 ties the bra on the door handle (loops it around the outside handle, looping on the inside handle is not visible), the door moves/vibrates back and forth for a time and then stops moving; at 8:13 a.m. (approximately five minutes after Patient 1 tied the bra to the door), Licensed Nurse (LN) E walked past room 210's partially open door and entered room 211 (across the hall from room 210); 8:18 a.m., LN E leaves room 211 and again walks past room 210's partially open door; 8:24 a.m., LN E goes into room 211 (passing 210's door); 8:30 a.m., room 210's door remained ajar (greater than approximately one foot) and the dark ligature (bra) was visible on the white door; 8:38 a.m., Mental Health Technician (MHT) D walked by room 210, looked into room 211, and then left. at 9:14 a.m., MHT D again walked past room 210. The video footage revealed between 8 a.m. and 9:20 a.m., no staff entered Patient 1's room. During a concurrent interview, the DON confirmed the bra was visible on the door (from the camera view).

During continued viewing of the surveillance camera footage with the DON and Director B on 11/14/23 at 10:15 a.m., the footage revealed at approximately 9:19 a.m. (approximately one hour and ten minutes after Patient 1 tied the bra to her door), Patient 1's roommate got out of bed and walked out of the room; she appeared to look at Patient 1 (behind the door, out of camera view) as she passed. The video revealed at 9:20 a.m., LN E arrived and entered room 210. She removed the bra from the door handles, took Patient 1 off the door, and began CPR (manual application of chest compressions and ventilation's [breathing] to patients in cardiac arrest). The video revealed LN G arrived and multiple staff arrived thereafter. The DON stated Patient 1 was Coded (Code Blue when CPR is performed) for approximately thirty minutes.

During an interview on 11/14/23 at 11:49 a.m., Supervisor C stated she was the supervisor of Unit 2 and was working (7 a.m. to 3:30 p.m.) the day of the incident (Patient 1's hanging). She stated she heard the Code (Code Blue; an emergency response code called when a patient is unresponsive and CPR is performed) called, responded to the Code, and said lots of people had arrived when she got there. She stated she had not yet rounded (checking on staff/patients to proactively address potential needs) on the unit when the Code Blue was called.

During the same interview on 11/14/23 at 11:49 a.m., Supervisor C stated MHT's duties included assistance with ADL's (activity of daily living, like showering), passing meal trays, possibly running group, and running the unit while nurses assessed their patients and charted (document in the medical record). On the morning of the incident, Unit 2 had two scheduled MHT's (MHT D and MHT H). Supervisor C stated MHT D was given assignment #1 (indicating he was responsible for the 15-minute safety checks, passing trays and assisting with showers during the first half of the shift, approximately 7:30 a.m. to 11:15 a.m.) while MHT H had assignment #2 (indicating she was to perform vital signs [measurements of the body's basic functions: temperature, heart rate, blood pressure, and respirations/breathing] and document them in the patient's medical record) for the first half of the shift. When asked about the acuity on Unit 2 that morning, Supervisor C stated mornings were typically busy and they also had a couple of manic patients (increased activity, energy or agitation ) who were hyperverbal (fast, increased speech), intrusive with staff, and hanging out at the nurse's station. She stated in addition, one patient (Patient 2) needed one-to-one supervision (a sitter) while she was out of her room (WOOR). Supervisor C stated they did not have a sitter for Patient 2 that morning and the duty "fell to staff." She stated she called Unit 1 for a sitter but MHT I (who was going to be the sitter) did not arrive on Unit 2 until approximately 8:30 a.m. (after Patient 1 had tied the bra to her door). Supervisor C stated LN E had assigned MHT D (who was also assigned to do the safety checks) to provide Patient 2's one-to-one supervision (until the sitter arrived), but the sitter took longer than expected. Supervisor C stated the nurses had said they would watch Patient 2's door and let MHT D know if she got up (and left her room). She stated the nurses were also "rounding" on Patient 2.

During the same interview on 11/14/23 at 11:49 a.m., Supervisor C was asked if MHT D had been reassigned from #1 duties (15-minute safety checks, passing meal trays, and showers the first half of the shift) to sitter duties. She stated MHT D was confused and did not understand he was on rounds (15-minute safety checks) at 8:30 a.m. (when the sitter arrived). Supervisor C confirmed Unit 2 was without a sitter for Patient 2 from 7:30 a.m. to 8:30 a.m.

Review of facility document (Patient 1's 15-minute safety checks) titled, "Patient Risk Assessment-BH-Auth (Verified)," dated 11/6/23, indicated, "Patient Observation Rounds... Pt (patient) Room # 210-A (Patient 1's room/bed)... Monitoring Level... Check Every 15 Minutes..." The document revealed the boxes at 8 a.m., 8:15 a.m. and 8:30 a.m. were empty (no documentation that the safety checks were performed). The boxes at 8:45 a.m. and 9 a.m. indicated Patient 1 was, "2 (calm)" and "B (in bedroom)." [Per camera footage, Patient 1 had hanged herself at approximately 8:09 a.m.].

Review of facility policy titled, "Policy: Documentation of Patient Care", subtitled, "Procedure" (revised 12/28/15) indicated, "B.2. Accurate, precise, pertinent... documentation of patient care in the medical record is critically important for the patient's continuum of care..."

During an interview on 11/14/23 at 1:26 p.m., Physician N stated he was Patient 1's psychiatrist while she was at the facility. He stated she had no history of attempted suicide (prior to the one on 10/23/2023), she had expressed family issues as stressors, and her family was supportive and visited daily. Physician N stated Patient 1's 5150 hold had been followed by a 5250 hold (a 14-day long involuntary treatment hold in a mental health facility). When asked why her hold was extended, he stated they had not yet developed a good discharge safety plan (written list of coping strategies and sources of support patients can use who have been deemed a suicide risk). Physician N stated Patient 1 was focused on discharge and verbalized her desire to go home. He stated he spoke to Patient 1 about a voluntary residential treatment option after she discharged from the facility but she became "almost paranoid" with the idea. Physician N stated Physician O had taken care of her over the weekend (Patient 1 died on Monday morning) and his expectation for Patient 1 prior to her death was for him to reassess her on Monday, speak with her family, and discharge her after a couple of days.

During the same interview on 11/14/23 at 1:26 p.m., Physician N was asked if he was aware Patient 1's 15-minute safety checks had not been completed around the time of her death. Physician N stated he had been notified, but staff should not have missed the checks. He stated for some patient's, 15-minutes safety checks were not (frequent) enough; he stated it can take (as little as) 7-8 minutes to hang yourself. Physician N stated missing safety checks was, "upsetting" and, "needs to be fixed."

During an interview on 11/14/23 at 2:03 p.m., MHT D stated on the day of the incident, he was in report (exchange of information between care givers at hand off for continuity of care) from 7 a.m. to 7:30 a.m. After report, he stated LN F told him to be the sitter for Patient 2 until MHT I arrived (he stated she arrived around 8:30 or 8:45 a.m.). He stated he looked in on Patient 2 about two times (she remained sleeping) while he passed breakfast trays and took a group of patients outside. While he was outside with the patients, he heard screaming (Patient 1's body had been discovered) and he stayed outside with the group of patients.

During the same interview on 11/14/23 at 2:03 p.m., MHT D stated he had not seen the assignment sheet that day (containing his duty to perform the 15-minute safety checks) as LN F had told him to watch Patient 2. He stated he had checked the board for the schedule (the board indicated daily meal times, outside activity times, and group activity times). MHT D stated they had their usual staffing the day of the incident with two licensed nurses (LN E and LN F), one medication nurse/tech (LN G) and two MHT's (himself and MHT H). When asked about the acuity on the unit, MHT D stated it was, "high." He stated he had an altercation with Patient 4, who was refusing to have his vital signs taken or weight obtained and Patient 5 was egging him on. When asked if they exhibited threatening behavior, MHT H stated Patient 4 was unpredictable and was raising his voice and and Patient 5 was encouraging him to fight. He had to repeatedly redirect them, and they were interfering with completing his work. MHT D stated the two patients were aggressive, he felt outnumbered as the only male staff on the unit and was "on guard" for his safety.

During an interview on 11/14/23 at 2:48 p.m., LN E stated she was the charge nurse (RN who oversees a department of nurses) the morning of the incident and Patient 1 was assigned to her. She stated she did not know Patient 1 (as she had not previously taken care of her) and she had not checked in with, nor had any interaction with Patient 1 prior to her death; she had rounded at approximately 7:50 a.m. but Patient 1 was sleeping. LN E stated during report, she learned Patient 1 had depression, had attempted suicide at home, had no issues (at the facility), was currently a low suicide risk (based on facility assessment tools), but was not ready for discharge. During report she also was told the unit was down (missing) a sitter (for Patient 2) and the supervisor (Supervisor C) told LN F that someone (MHT I) was coming from Unit 1 to help. LN E stated MHT D was told to do rounds (15-minute safety checks), including Patient 2 (who needed a sitter while out of her room). LN E stated she and LN F would watch Patient 2's door to see if she left her room. She stated MHT H was doing patient vital signs and weights with two students and MHT D was doing the safety rounding. When asked if she was aware there was confusion with the sitter assignment after MHT I arrived on the unit, she stated she was not aware and said she thought she was clear with the assignment.

During the same interview on 11/14/23 at 2:48 p.m., LN E stated the unit was very busy and very loud the morning of the incident. She stated they had a couple of loud, verbal, impulsive, psychotic (disruption of thoughts and perceptions; some loss of contact with reality) patients who were more acute (symptoms appearing, changing, or worsening rapidly). In addition, she stated patients were waiting for their medications, breakfast and coffee at 8 a.m. LN E stated Patient 1's roommate came down the hall and told them something was on her roommates neck. LN E stated when she arrived at the room, the door was open and Patient 1 was on the back of the door. She lifted her up and released the bra (around her neck) and shouted "CPR." LN E stated she began CPR, LN F performed chest compressions. EMS (Emergency Medical Services; paramedics) arrived quickly.

Review of Patient 1's medical record revealed a nursing note authored by LN E, dated 11/6/23 at 12:24 p.m., that documented the incident and indicated, "The room mate (sic) of this patient approached writer at the nurses station asking if I could check on her roommate because she had 'something on her neck'(.) Writer immediately went to room and found pt (patient) at 9:23 (a.m.)... with a black bra wrapped around her neck adn (sic) attached to the inside and out (sic) door handle. Writer lifted pt up slightly to lessen tension and unwrap the bra freeing pt and laying her on (the) ground. Pt was in upright sitting position slightly leaning forward when found. Writer checked for pulse which was not present and checked respiration/chest rise which was not present either. Immediately yelled for code blue... 0923 (a.m.) CPR started... 0928 EMS arrived... 0931 ... EMS took over code completely... 0954 time of death..."

During a viewing of the surveillance camera footage (camera located outside Patient 1's room), on 11/15/2020 at 9:30 a.m., the DON and Director B viewed the tape, described events, and identified the staff present prior to the incident from approximately 6:30 a.m. to 8 a.m. (timeframe prior to Patient 1 hanging herself). At 6:30 a.m., room 210's door if fully open and Patient 1 is lying on top of her bed (not under the covers). At 7:23, MHT R (night shift staff) glanced into room 210 and then into room 211. At 7:53 a.m., Patient 1 was moving near the bedside table. No safety check had been done since 7:23 a.m. At 7:57 a.m., MHT H did safety rounds for room 210 (approximately thirty-four minutes after the last safety check). The DON verified no safety checks had been done for approximately thirty-four minutes.

During a telephone interview on 11/15/2023 at 11:02 a.m., MHT H stated on the day of the incident, Unit 2 was short staffed (too few staff), as they had no one to function as Patient 2's sitter. MHT H stated they were going to send someone over from another unit (to be the sitter). She stated she was doing patient vital signs with two students and LN F told MHT D to do the 15-minute safety rounding for the first part of the shift (7:30 a.m. to 11:15 a.m.) and she would do (safety rounding) the second half of the shift (11:30 a.m. to 3:15 p.m.). She stated she did the first two safety rounds at 7:30 and 7:45 a.m. because the binder (where rounding was documented) was "sitting there," so she picked it up because nobody was doing it. She stated Patient 1 was still in bed when she did the two sets of rounds. She stated Patient 2, who needed a sitter, was still sleeping. MHT H stated at the time of the incident, she was documenting vital signs into patient medical records when she heard screaming. She ran down the hall but never made it into room 210; she stated she saw staff doing CPR on Patient 1.

During the same interview on 11/15/2023 at 11:02 a.m., MHT H stated the acuity on Unit 2 was a little high the morning of the incident and it was, "hectic." When asked what was hectic, she stated a few patients did not want the food on their trays but they had no staff available to go to the kitchen for alternate food, someone wanted a shower, they had a couple of psychotic patients, and MHT D was watching Patient 2 and passing meal trays. She stated the unit was also loud. She stated a patient was yelling and screaming, one patient (who was on phone restriction) was calling 911, and one patient was putting on another patient's clothes.

During the same interview on 11/15/2023 at 11:02 a.m., MHT H was asked about the fifteen minute rounding process. She stated it sometimes took the entire fifteen minutes to complete the checks as you might have to look for a person and find them before moving to the next person. She stated they also passed meal trays while rounding. She stated sometimes the fifteen minute rounds could not be done on time because she was pulled away to do these other duties. She stated she got interrupted while doing rounds when patient's requested shower assistance and requested bathrooms be unlocked (bathrooms were routinely locked and patients had to request entry from staff). She stated staff had brought this issue up at Staff Meetings (staff gathering to discuss patient care, work-related issues, and departmental or institutional policies), management said they would look into it, but no changes were made prior to the incident.

Review of facility policy titled, "Facility Policy and Procedure: Supervision And Observation Of Patients," subtitled, "E. Visual Checks" (revised 10/15/19) indicated, "1. The performance standard is to visually check each patient every 15 minutes... 3. Visual checks include observation of patient activity. This means evidence of breathing even while the patient appears to sleep...

During a telephone interview on 11/15/2023 at 11:38 a.m., LN G stated she was the medication nurse the morning of the incident and stayed in the medication room (passing patient medications). She stated it was, "unfortunately" very busy that day, it was very loud, and the patients were more acute and constantly in the nurse's station. She stated patients usually had lots of requests in the morning (including medication and breakfast issues) and staff were focused on vital sign completion. When asked if the unit had psychotic patients that morning, LN G stated, "very much so." She stated the patients were high maintenance, a couple of guys were friends (one minute) but the next minute they wanted to fight, and a female patient was arguing with staff because she did not want to be at the facility. LN G stated they were short staffed and thought they did not have staff for the patient who needed one-to-one staffing (sitter). She stated the unit was challenging and the quiet patients got missed. LN G stated she heard LN E say, "Help, help, help," she ran to the room (210), and a Code Blue was called. She stated we (staff) fought hard (for Patient 1) and EMS fought hard.

During a telephone interview on 11/15/23 at 1:30 p.m., LN F stated she knew Patient 1 (from previously taking care of her) and stated Patient 1 was guarded with nursing staff and shared minimal information with them; she stated Patient 1 shared more with the physicians (as reflected in the physician progress notes). She stated Patient 1 seemed afraid while out of her room, did not verbalize what was going on with her, and stayed in her room. She stated Patient 1 was a quiet person who spent time writing, praying, and visiting daily with her family. LN F stated Patient 1's suicide risk score (C-SSRS, suicide assessment tool) always indicted she was not suicidal. On the morning of the incident, LN F stated she was the second nurse while LN E was the charge nurse. She stated LN E's patient told her that her roommate needed to be checked and LN E went to the room. LN F stated she heard LN E scream and she then went to room 210, someone called a Code Blue, she and LN E began CPR, and EMS staff arrived.

During the same interview on 11/15/23 at 1:30 p.m., when asked about having a sitter on Unit 2, LN F stated they did not think they were down a sitter. She stated Patient 2 needed one-to-one observation while she was out of her room. LN F stated she assumed the 15-minute safety checks covered this and when Patient 2 was out of her room, they would need a sitter. She stated Patient 2 was sleeping until MHT I (the sitter) arrived. LN F stated MHT D was watching Patient 2 (who was sleeping) and LN E leaned over the nursing station desk and told him he did not have to stand there (in front of the room) and told him he could do the rounding (15-minute safety checks). She stated MHT D began passing breakfast trays and she thought he was (also) rounding.

Review of facility policy titled, "Facility Policy and Procedure: Supervision And Observation Of Patients," subtitled, "F. One-To-One Observation" (revised 10/15/19) indicated, "...4. At all times patients who are on 1:1 (one-to-one) supervision must be visible to the assigned employee... 5. The patient who is on 1:1 supervision must be the primary focus of the assigned employee... a. Except when charting, employees assigned to 1:1 observation may not read, write, or participate in any activity that does not involve the assigned patient or that might draw the employee's focus away from the patient..." Language addressing supervision regarding WOOR was not located in the policy.

During an interview on 11/15/23 at 2:11 p.m., MHT I (the sitter) stated she had initially been assigned to Unit 1 on the morning of the incident, but she was then pulled to unit 3 or 4. She arrived on Unit 3 (incorrect unit) and then headed to Unit 2. She stated she arrived on unit 2 approximately 8:45 a.m. to 9 a.m. and Patient 2 was sleeping. She stated she saw a nurse running down the hall, heard someone call a Code Blue, but had no involvement in the code (or the incident).

During an interview on 11/15/23 at 2:22 p.m., Supervisor R stated he was assigned to Units 3 and 4 the morning of the incident, heard the Code Blue called, responded to the code, and instructed staff to call 911 (national phone number to request emergency medical/police/fire assistance). He stated he escorted EMS staff to Unit 2 and Administrator A asked him to view the camera footage of the incident (during the Code Blue) to determine what time Patient 1 was last seen awake or walking and check who was doing the safety rounds. When asked what he saw on the footage, Supervisor R stated he saw Patient 1 struggling in her room, lying on the bed, then lying between the beds. He stated he saw a, "a black garment on the (door) handle at approximately 8:07 a.m. or 8:09 a.m. He confirmed the Code Blue was not called for approximately 1 hour and 10 minutes after the garment was on the door handle.

During an interview and concurrent document review on 11/16/23 at 10:30 a.m., the DON was queried about patient belongs. Review of facility document titled, "Visitation Guidelines" (undated) indicated, "... For safety reason, please DO NOT BRING the following items... "Clothing or other items with belts, cords or strings including shoes with laces..." The DON was asked if it was okay for patients to have their bras, as bras had straps (similar to strings). The DON stated the policy indicated no shoe laces, strings on hooded sweatshirts, et cetera and brassieres were okay at the time.

During an interview and concurrent review of Patient 1's treatment plans (mental health treatment plans; explains the type and frequency of support various healthcare professionals provide to the patient) on 11/16/23 at 10:30 a.m., the DON confirmed the plan titled, "Problem #1 Unsafe Behaviors: Danger to self..." indicated, "... pt will remain safe and not cause harm to self or others throughout hospitalization..." was still in place (not resolved) at the time of her death. The interventions in the treatment plan included, "... Close observation every 15 minutes (and) Monitor room/environment every shift for unsafe items..." The DON reviewed the treatment plan titled, "Problem #6 Discharge Readiness" indicated, "... pt will develop a safety plan before discharge..." and confirmed it was not yet developed at the time of Patient 1's death. She stated Physician N was going to reevaluate Patient on Monday (the day of her death) and assess her for discharge readiness. The DON stated Patient's C-SSRs (suicide risk assessment tool) was high (meaning high suicide risk) when she was admitted (10/30/23), but her risk had measured low on the subsequent tests/measurements.

During an interview on 11/16/23 at 11:04 a.m., the DON was asked who was responsible for ensuring the MHT's performed the fifteen minute safety checks. She stated licensed nurses should ensure they are done as well as assume the overall responsibility of the patient.

Review of facility job description titled, "Mental Health Technician - 77296," subtitled, "Job Summary" (updated 8/17/2023) indicated MHT's, "Provide direct and indirect care, under the direction of the registered nurse... for a patient or an assigned group of patients..." Under subtitle, "Essential Functions," the document indicated, "... Assists in maintaining program function including... patient safety checks..."

Review of facility policy titled, "Facility Policy and Procedure: Behavioral Health Suicide Risk Assessment and Prevention," subtitled, "Policy..." (revised 6/15/2020) indicated, "A. Policy... Patients at risk for suicide require intensive support, close observation... and application of protective measures for their emotional and physical well-being..." Under subtitle, "B. Procedure," the document indicated, "1. Suicide Risk Assessment... d. The suicide risk assessment will include specific risk factors including: i. Previous attempt(s)... 5. Patient Monitoring a. All patients will be monitored at least every 15 minutes...

Review of facility policy titled, "Safety Management Plan" subtitled, "Policy" (revised 8/30/2018; reviewed 4/28/2022) indicated, "A. Policy The hospital is committed to providing quality of service to customers by providing a safe care and work environment."










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2. During a concurrent interview and medical record review on 11/16/23 at 11:11 a.m., with Administrative Staff K, Patient 3 was admitted on 11/12/23 with the diagnosis of depression. Review of the physician Order Sheet dated 11/12/23 at 1:52 p.m. indicated "...15 minute checks until discharge, Unless otherwise indicated...".
Review of the Patient Observation Rounds Every 15 Minutes dated 11/13/23 revealed at 23:30 (11:30 p.m.) and 23:45 (11:45 p.m.) the 15 minute checks were not completed.
Administrative Staff K confirmed the missing 15 minute checks.

Based on interview, and document review, the hospital failed to ensure there was a hospital-wide Quality Assurance Performance Improvement (QAPI) program, as evidenced by:

1. The hospital failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
(Cross Reference A 273).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.

Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Failure to develop a comprehensive program that identified opportunities for improvement, may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 11/16/23 at 1:45 p.m., the hospital's performance improvement plan was reviewed with Director B. She described a program that was implemented by the Performance Improvement Committee. It was noted the program was limited to evaluating emergency preparedness for equipment, policy and procedure, education and training, the results of resuscitation (code blue). She stated the hospital's Performance Improvement Committee had not chosen performance improvement indicators for emergency preparedness and nurse staffing to demonstrate the hospital was able to improve health outcomes.

Review of the hospital document titled, "Performance Improvement Committee Minutes ", dated 6/20/23, indicated "...New Business...Administrator A emphasized the need for more concern about safety in the building. He sees there is room for improvement and suggested Nursing Managers/Clinical Educator to educate staff on the safety risks of not being attentive to the doors, and possible elopements. Staff need to be more vigilant and alert to the risks in their environment. Counseling may be needed if education is not effective.
Staffing is a concern that affects patient safety and staff morale. Suggestion of creating a position on where one staff will do Q5 (every 5) min (minute) safety checks to monitor 1:1's and eliminate the need for multiple 1:1 staff. Supervisory Staff need to work on their decision making. Reminder to report all findings we see on the unit to the department head..."

Review of the hospital document titled, "Performance Improvement Committee Minutes ", dated 9/27/23, did not demonstrate the QAPI committee had implemented measures to improve safety risks, emergency preparedness and nurse staffing. There was no documentation to demonstrate the concerns identified on 6/20/23 were discussed on 9/27/23.

During an interview on 11/16/23 at 2:35 p.m., DON stated she attended all QAPI meetings. DON stated that at the QAPI committee meetings they tried to come up with solutions to problems. DON stated hiring was a focus, but increasing the number staff on the staffing matrix had not been an option because of budgetary restrictions. DON stated she did not recall any staffing issues coming up at the May 2023 QAPI committee meeting that required any follow up at the subsequent QAPI meeting.

There was no documentation the hospital ensured a comprehensive performance improvement program was implemented, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided, to include safety risks, emergency preparedness and nurse staffing.

Based on interview and record review, the hospital failed to provide an organized Nursing Service for one of 30 sampled patients (Patient 1) as evidenced by:

1. The hospital failed to have a staffing system in place based on the number and acuity of patients. Patients would not receive nursing care based on their individual, sudden or emergent behavioral health needs. (Cross Reference A-0392).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Nursing Services.

Based on observation, interview, and record review, the hospital failed to: 1. Communicate clearly to staff the assigned duties for the AM shift on 11/6/23 and ensure those duties were carried out, and 2. Staff to acuity per hospital staffing policy.
This failure resulted in Patient 1 hanging herself to death in her room and not being found for over one hour, and had the potential to result in unsafe conditions for patients and staff.

Finding:

1. During a camera feed review and concurrent interview on 11/14/23 at 10:10 a.m. with Director of Nursing (DON) and Director B, video footage of Patient 1's bedroom door from the hallway on 11/6/23 between 8 a.m. and 9:30 a.m. revealed that at 8:10 a.m., Patient 1 wrapped a black strap around the outside door handle of her bedroom door. She closed the door half-way, and at 8:11 a.m. Patient 1 disappeared from camera view. Between 8 a.m. and 9:20 a.m., no staff entered Patient 1's room. At 9:19 a.m., Patient 1's roommate awoke, got up from her bed and went out into the hallway, and at 9:20 a.m., Licensed Nurse (LN) E entered Patient 1's room. LN E removed the black strap from the door handle. DON confirmed the black strap was Patient 1's bra strap. The video footage revealed LN G entered Patient 1's room while LN E laid Patient 1 on the floor and began giving Patient 1 rescue breaths. LN E removed the bra from around Patient 1's neck and continued resuscitation efforts.

Review of Patient 1's medical record revealed a document "Patient Observation Rounds," dated 11/6/23, that indicated the 8 a.m., 8:15 a.m., and 8:30 a.m. rounds were not signed off as completed.

Review of the Unit 2 staffing assignment sheet for AM shift (7 a.m. to 3:30 p.m.) indicated there were two registered nurses (LN E and LN F), one licensed vocational nurse (LN G), and two MHTs (mental health technicians) scheduled to work on the unit. LN E was assigned as Patient 1's nurse. LN E was assigned ten patients and LN F was assigned nine patients.

During a record review and concurrent interview on 11/14/23 at 11:50 a.m. with Supervisor C and DON, Supervisor C stated she worked 7 a.m. to 3:30 p.m. on 11/6/23. Supervisor C stated the role of the MHTs was to run the unit while the registered nurses did their assessments of the patients and their charting. Supervisor C stated the MHTs' duties included attending to the patients' ADLs (activities of daily living, such as bathing, grooming, and toileting), meals, run groups (patient group activities), and doing rounds every 15 minutes (safety check of each patient). Supervisor C reviewed the staffing assignment sheet for Unit 2 for AM shift on 11/6/23, and stated MHT D's assignment for the shift was to do the 15-minute checks from 7:15 a.m. to 11:15 a.m. Supervisor C stated that on the morning of 11/6/23 they did not have a sitter (staff designated to closely supervise one patient for safety and has no other duties, also called one-to-one) for a patient who needed one (Patient 2). When asked the reason the patient did not have a sitter assigned, Supervisor C stated the Noc shift (11 p.m. to 7 a.m.) supervisor failed to notice a sitter was needed for the AM shift on Unit 2. Supervisor C verified Patient 2 had a sitter on the Noc shift (11/5/23 into 11/6/23). Supervisor C stated LN E reassigned MHT D to be one-to-one with Patient 2 until a sitter could be obtained. DON stated the sitter, MHT I, arrived to Unit 2 at 8:30 a.m.

Continuing the record review and concurrent interview on 11/14/23 at 11:50 a.m. with Supervisor C and DON, Supervisor C stated she (Supervisor C) and LN E (the charge nurse) were responsible for reassigning the staff when the additional staff, MHT I, came to Unit 2. Supervisor C stated when staff were reassigned in situations like that, the new duty assignments were communicated informally amongst the staff. Supervisor C verified that she and LN E assumed MHT D understood that he would go back to his original assignment of doing the 15-minute checks once MHT I came in. Supervisor C reviewed Patient 1's document "Patient Observation Rounds" dated 11/6/23 and stated her expectation was that MHT D was supposed to be doing the 15-minute checks that were not signed off at 8 a.m., 8:15 a.m., and 8:30 a.m. (the time during which Patient 1 hanged herself). When queried, DON stated the charge nurse was ultimately responsible for making sure the 15-minute safety checks got done.

During an interview on 11/14/23 at 2 p.m., MHT D stated he recalled that on the morning of 11/6/23 he was given a one-to-one assignment until a sitter came. MHT D stated MHT I arrived to his unit to relieve him around 8:30 or 8:45 a.m. MHT D stated that his understanding at the time was that when MHT I arrived, he would continue passing the breakfast trays and then take the patients outside. MHT D stated he never looked at the staffing assignment sheet that day because he was told to do the one-to-one assignment as soon as he arrived to the unit.

During an interview on 11/14/23 at 2:48 p.m., LN E stated her duties were to assess the patients assigned to her, work with the patients' treatment plans, and work with the case manager. LN E verified Patient 1 was her patient on 11/6/23. LN E stated she became aware they were short a sitter as soon as she came out of report (exchange of information between care givers at hand off for continuity of care). LN E stated Patient 2 was asleep, and the sitter was only required when Patient 2 was out of her room, so she told MHT D to do his rounds and she would let him know if the patient woke up. LN E stated she did not know MHT D was unclear on his assignment after MHT I arrived. When queried, LN E stated she would check in verbally with the staff to ensure the 15-minute checks were getting done.

During an interview on 11/15/2023 at 11:02 a.m., MHT H stated on 11/6/23, Unit 2 was short staffed as they had no one to function as Patient 2's sitter. MHT H stated they were going to send someone over from another unit (to be the sitter). She stated she was doing patient vital signs with two nursing students and LN F told MHT D to do the safety rounding for the first part of the shift (7:30 a.m. to 11:15 a.m.) and she would do the second half of the shift (11:30 a.m. to 3:15 p.m.). She stated she did the first two safety rounds at 7:30 and 7:45 a.m. because the binder (where rounding was documented) was "sitting there," so she picked it up because nobody was doing it. She stated Patient 1 was still in bed when she did the two sets of rounds.

During an interview on 11/15/23 at 1:30 p.m., when asked about having a sitter on Unit 2 on 11/6/23, LN F stated Patient 2 needed one-to-one observation while she was out of her room. LN F stated she assumed the 15-minute safety checks covered this, and when Patient 2 was out of her room, they would need a sitter. She stated Patient 2 was sleeping until MHT I (the sitter) arrived. LN F stated MHT D was watching Patient 2 (who was sleeping) and LN E leaned over the nursing station desk and told him he did not have to stand there (in front of the room) and told him he could do the rounding (15-minute safety checks). She stated MHT D began passing breakfast trays and she thought he was (also) rounding.

Review of hospital policy "Acuity / Staffing Plans," last revised 7/15/19, indicated, "All delivery of nursing care to patients is assigned by and under the supervision of registered nurses."

Review of hospital policy "Assignment for Patient Care," last revised 3/2020, indicated, "Assignment of nursing care duties is the responsibility of the shift charge nurse. Assignments are made in accordance with the staffing plan. The shift charge nurse is responsible to assign duties to each nursing staff on duty . . . . An RN will be responsible to direct, delegate, and coordinate the care delivered."

Review of hospital policy "Shift Charge Nurse Responsibilities," last revised 3/2020, indicated, "Throughout the shift the Charge Nurse will be responsible for the ongoing assessment of patient needs, and the adjustment of patient care assignments, as indicated. The Charge Nurse will be responsible for ensuring that all hospital [policies and procedures] and related regulations are followed, and that patient care and unit program are conducted in a manner that reflects the mission and philosophy of the hospital."

Review of hospital policy "Patient Safety - An Organizational Approach," last reviewed 12/15, indicated, "It is the philosophy of this organization that safety is everyone's responsibility and therefore, must be a collaborative effort."

2. Review of hospital document "Core Staffing Matrix," not dated, indicated the number of staff to be scheduled for each discipline depending on the patient census for each of the four units. The staffing matrix indicated that for AM shift on Unit 2, for a census up to 11, there would be one RN and one Licensed Psychiatric Technician (LPT) or one LVN. For a census of 12, there would be one RN, one LPT or LVN, and one MHT. For a census of 13 to 16, there would be 2 RNs, 1 LPT or LVN, and 1 MHT. For a census of 17 to 21, there would be 2 RNs, 1 LPT or LVN, and 2 MHTs.

During a record review and concurrent interview on 11/14/23 at 11:50 a.m. with Supervisor C, Director B, and DON, when asked about the acuity of Unit 2 on the morning of 11/6/23, Supervisor C stated there were a couple of patients on Unit 2 that were manic and hyperverbal (fast, increased speech), so it was loud and there was a lot going on. Supervisor C stated the manic patients were not violent, but they were hanging around the nurses' station and intrusive with staff. DON stated the Unit 2 census was 19 of 21 beds. When asked how acuity was determined, Supervisor C stated they did not use a scale, they just passed it on to the next supervisor what happened, they described what they were dealing with during the shift. When asked how it was determined that a ratio of one nurse to nine or ten patients was safe, DON stated the staff felt it was manageable, unless there were higher acuity patients. When asked about increasing staff on a unit that has higher acuity patients, DON stated "We don't." DON stated the nurse-to-patient ratio of one-to-nine and one-to-ten had been in place since she started working at the hospital seven years ago. Review of hospital policy "Acuity / Staffing Plans" indicated, "The total number of nursing employees assigned to a unit is determined by: . . . The level of acuity of individual patients, and the overall level of acuity of the patient population as a [whole]." When queried about this verbiage in the hospital policy, Supervisor C, DON, and Director B denied there was any tool or document that the nurses used to assign acuity. DON verified the nurse-to-patient ratio stayed the same no matter what the acuity of the patients or the unit was and no matter how many one-to-one patients there were in the nurse's assignment.

During an interview on 11/14/23 at 2:05 p.m., when asked about the acuity on the unit the morning of 11/6/23, MHT D stated it was "high." MHT D stated that he was having a problem with two male patients. MHT D stated he recalled one was refusing to have his vital signs and weight taken and the other was encouraging him to fight. He was having to repeatedly redirect them, and they were interfering with completing his work. MHT D stated the two patients were aggressive, he felt outnumbered as the only male staff on the unit and was "on guard" for his safety. MHT D stated the two male patients made him feel scared and distracted. MHT D verified the usual staffing on the unit was two nurses, two MHTs, and a medication nurse.

During an interview on 11/14/23 at 2:48 p.m., LN E stated she worked on Unit 2, sometimes as charge nurse, sometimes as the "second nurse." LN E stated the morning of 11/6/23 was "really busy, a lot of psychotic patients responding to internal stimuli." LN E stated it was a loud, rough morning, the patients were loud, "everyone was amped up." LN E stated she had never been asked to participate in a survey about whether the staffing matrix worked or did not work for the nurses.

During an interview on 11/15/2023 at 11:02 a.m., MHT H stated the acuity on Unit 2 was a little high the morning 11/6/23 and it was "hectic." When asked what was hectic, she stated a few patients did not want the food on their trays but they had no staff available to go to the kitchen for alternate food, someone wanted a shower, they had a couple of psychotic patients, and MHT D was watching Patient 2 and passing meal trays. She stated the unit was also loud. She stated a patient was yelling and screaming, one patient (who was on phone restriction) was calling 911, and one patient was putting on another patient's clothes.

During the same interview on 11/15/2023 at 11:02 a.m., MHT H was asked about the fifteen minute rounding process. She stated it sometimes took the entire fifteen minutes to complete the checks as you might have to look for a person and find them before moving to the next person. She stated they also passed meal trays while rounding. She stated sometimes the fifteen minute rounds could not be done on time because she was pulled away to do these other duties. She stated she got interrupted while doing rounds when patient's requested shower assistance and requested bathrooms be unlocked (bathrooms were routinely locked and patients had to request entry from staff). She stated staff had brought up this issue at Staff Meetings (staff gathering to discuss patient care, work-related issues, and departmental or institutional policies), management said they would look into it, but no changes were made prior to the incident.

During an interview on 11/15/2023 at 11:38 a.m., LN G stated she was the medication nurse the morning of 11/6/23 and stayed in the medication room (passing patient medications). She stated it was "unfortunately" very busy that day, it was very loud, and the patients were more acute and constantly in the nurses' station. She stated patients usually had lots of requests in the morning (including medication and breakfast issues) and staff were focused on vital sign completion. When asked if the unit had psychotic patients that morning, LN G stated, "Very much so." She stated the patients were high maintenance, a couple of guys were friends one minute but the next minute they wanted to fight, and a female patient was arguing with staff stating she did not want to be at the facility. LN G stated they were short staffed and thought they did not have staff for the patient who needed one-to-one (sitter). She stated the unit was challenging and the quiet patients got missed.

During an interview on 11/16/23 at 2:25 p.m., Administrator A verified the hospital did not have a system for determining patient or unit acuity for staffing purposes and stated they staffed the units according to the staffing matrix.

During an interview on 11/16/23 at 2:35 p.m., Administrative Staff P stated the staffing matrix had been in use since 2018. Administrative Staff P stated she obtained information on the acuity of the units by calling the units and asking about acuity and any special observation needs, such as one-to-one patients. Administrative Staff P stated she would also reach out to the intake staff to ask about potential admissions to the hospital. Administrative Staff P stated she would then run the staffing assignments by DON and then post them.

During an interview on 11/16/16 at 2:35 p.m., DON verified the hospital did not have an acuity rating system for patients that they used in order to anticipate an increased need for staff. DON stated high acuity patients affected the amount of time required of staff. DON stated for example high acuity patients may have increased requests from staff, or require staff to make an increased number of calls to the doctor.

Review of hospital policy "Acuity / Staffing Plans" indicated, "The total number of nursing employees assigned to a unit is determined by: a. The total number of patients. b. The ability of each of the patients to meet their own self -care needs, and the amount of assistance required by individual patients to meet their own needs, and to function safely and effectively on the unit. c. The level of acuity of individual patients, and the overall level of acuity of the patient population as a [whole]. d. The needs of individual patients for special assistance, supervision, or intervention such as special precautions (for suicide risk, elopement risk, poor impulse control., 1:1 supervision, etc.). 4. The skill mix and level of licensure of employee assigned to the specific unit will be based on the complexity and intensity of the needs of the patients being served."

Based on observation, interview, and document review, the hospital failed to maintain the hospital facilities and equipment to meet the needs of all patients, as evidenced by failure to:

1. Adequately maintain the hospital's buildings and equipment (both facility equipment and patient care equipment). 2. Failed to develop policy and procedure to ensure the washer/dryer used to clean patients' own laundry, housed in Unit 1, Unit 2, and Unit 3 were evaluated for proper temperatures, proper use and proper cleaning post use. 3. Failed to provide laboratory services in a safe, clean setting. (Cross Reference A-701).

4. Adequately ensure life safety from fire requirements were met.
(Cross Reference E004, E0025, K920, K781, and K926).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Physical Environment.

Based on observation, interview and document review, the hospital failed to:

1. Ensure preventative maintenance was performed on patient care equipment; hospital equipment. This had the potential to increase hazard risks to patients, staff and visitors.
These failures had the potential to cause harm to patients'/staff/visitors.

2. Failed to develop policy and procedure to ensure the washer/dryer used to clean patients' own laundry, housed in Unit 1, Unit 2, and Unit 3 were evaluated for proper temperatures, proper use and proper cleaning post use. These failures had the potential to cause cross-contamination of patients' soiled laundry.

3. Failed to provide laboratory services in a safe, clean setting. This failure had the potential to cause patient laboratory specimens to be improperly handled and resulted.

Findings:

1. a. During a concurrent tour of the Adolescent Unit and interview on 11/13/23 at 2:15 p.m., Supervisor R confirmed the Admitting Suite (used to assess patients) privacy curtain was not in good repair and improperly hung. The room was unkept, used for storage as it contained a weight scale, computer on wheels, five chairs, desk, blood pressure/pulse oximetry on wheels (used to measure blood pressure and oxygen levels) was unkept and over crowded with equipment.

b. During a concurrent tour of the hospital and interview on 11/13/23 at 3:00 p.m., Administrative Staff J confirmed a three-shelf rolling cart contained linens (towels, washcloths, blankets, sheets, patient gowns and disposable pants) used for patients, was observed in the staff break room uncovered. Administrative Staff J stated the hospital had designated linen closets.

Review of the policy and procedure titled "LINEN AND LAUNDRY" last reviewed 10/29/21, indicated "...Clean linen is transported in covered containers and stored separately..."

c. During a concurrent tour of the hospital and interview on 11/14/23 at 1:25 p.m., with Administrative Staff, J, the lobby ceiling had black film around the air vent, the sink in bathroom-2 had not been upgraded, the fan in the ceiling made loud noise, floor tiles were loose.

d. During a concurrent tour of the hospital and interview on 11/14/23 at 1:40 p.m., with Director B and Administrative Staff J, the Day Room had a gel hand sanitizer located in the closet ith an expiration date of 7/2022. Under the foot ball table legs were seven socks. The patient telephone cord had wires exposed. The garden area several tiles (greater than 10) were observed broken.

e. During a concurrent tour of the north side of the hospital grounds and interview with Administrative Staff J on 11/15/23 at 11:00 a.m., observation revealed weed barriers were exposed and shredded. The fence/gate was in leaning and had exposed boards that were rotted.

f. During a concurrent tour of the hospital and interview with Administrative Staff J on 11/15/23 at 11:40 a.m., observation revealed the floor mat at the lobby/hospital entrance had torn edges.
Administrative Staff J stated the hospital was responsible for obtaining new floor mats.
Review of the Unit 2 Seclusion Room observation revealed base boards with dry rot. The ceiling, the foot of the bed and the walls were soiled with unknown substance. Administrative Staff J stated the room had been clean and was ready to accept a patient.

Review of the policy and procedure titled "...PATIENT DISCHARGE ROOM CLEANING", last reviewed 10/18/21, indicated "...Disinfect exterior and interior surfaces of all furniture and fixtures...Check windows and walls...used germicidal solution or wall cleaner..."

g. During a concurrent tour of the hospital and interview with Administrative Staff K on 11/15/23 at 2:55 p.m., observation of the Physician Consult Room Unit 3 used by staff and patients revealed a three seat couch with torn fabric.

Review of the policy and procedure titled "...PROGRAM RESPONSIBILITY", last reviewed 7/10/23, indicated "...The Hospital recognizes a responsibility to provide a preventative and corrective maintenance program...Goals of the maintenance program include: a. To prolong the life of buildings and equipment b. To assure safe and reliable performance c. To assure compliance with applicable codes and regulations..."

2. a. During the tour on 11/15/23 at 12:00 p.m., Unit 1, Unit 2 and Unit 3 Patient Laundry rooms contained a wash machine and dryer. Administrative Staff J stated hospital staff would use the washer and dryer to clean patients' clothing. The Patient Laundry rooms did not include a policy/procedure on the use of the washer and dryer. Patient Laundry rooms did not include a procedure staff would follow to ensure the washer and dryer reached minimum temperatures. Patient Laundry rooms did not include a procedure on the disinfection procedure of the laundry units between patients.

b. During the tour on 11/15/23 at 12:00 p.m., Unit 1 Patient Laundry room had an rag under the cold water faucet. Bugs and spiderwebs, dust and trash on the floor were observed.
Unit 2 Patient Laundry room had dust on the floor and on the lamp lighting the room.
Unit 3 Patient Laundry room had dust on the floor and the dryer lint trap's screen had been taped with a silver substance to the plastic frame.
Administrative Staff J confirmed the observations for Unit 1, Unit 2, and Unit 3's Patient Laundry rooms.

The hospital was not able to provide surveillance documentation by the performance improvement/risk director, that the Infection Preventionist and the Manager of Facilities, had assessed that the Patient Laundry rooms were safe and ready for use for Unit 1, Unit 2 and Unit 3.

During and interview with Director B on 11/15/23 at 1:15 p.m., Director B stated the hospital did not have a policy and procedure on the use and maintenance for the washer and dryers used to clean patient laundry for Unit 1, Unit 2 and Unit 3.

3. A. During a concurrent tour of the Laboratory Room/Exam Room and interview with Administrative Staff K on 11/15/23 at 2:55 p.m., Administrative Staff K stated the Laboratory Room/Exam Room was used as the laboratory for the hospital. The room contained the following:
a. a patient exam table, no current preventative maintenance identifiers were noted.
b. the Pharmacy Night Locker (a after hours medication drug storage).
c. an open bin containing personal health information
d. a counter with a sink, multiple specimen tube holders containing substances, not labeled or dated next to the hand washing sink with no delineation for clean and dirty areas identified
e. a centrifuge with no identifier the preventative maintenance and calibration had been performed
f. two gray top vacutainers expired 4/30/23
g. two blue top vacutainers expired 9/30/23
h. two blue top vacationer expired 6/30/23
i. The CLIA (Clinical Laboratory Improvement Act) certificate expired 10/23/22

Administrative Staff K confirmed the observations and could not provide the surveyor with dates the Laboratory Director, Infection Preventionist, Manager of Facilities had made environmental rounds in the Laboratory Room/Exam Room.

Review of the policy titled "LABORATORY SERVICES", last revised 10/10/16 indicated "...To provide laboratory services that meet state and regulatory agency criteria...In accordance with federal regulations...and stat law...all testing of biological specimens at the hospital is overseen by the ...Clinical Laboratory Medical Director..."

B. The closet where the laboratory specimen refrigerator was stored had dust on top of the refrigerator, on ceiling fan vent. Two packages containing 20 disposable collection swabs with the expiration date of 5/2022. There were no logs to denote temperature monitoring.

Review of the policy titled "REFRIGERATORS AND LOGS", last reviewed 10/29/21 indicated "...Refrigerator temperatures are checked based on a preestablish schedule, and readings are documented electronically on a graph or manually on the Refrigerator Log..."

Based on interview and document review, the facility failed to demonstrate an individual was qualified through education, training, experience or certification in infection prevention and control and was appointed by the governing body.

Findings:

During a concurrent interview and document review on 11/16/23 at 9:10 a.m., Director B stated IC O was the facility's Infection Prevention and Control Practitioner (ICP). Director B stated IC O had not been to the facility this year.

Review of the Infection Prevention Committee Minutes dated 5/11/22 indicated six attendees. IC O was not present during the Infection Control Meeting.

Review of prior Infection Prevention Committee Minutes dated 9/16/20, 6/17/20, 3/11/20 indicated IC O was present for the Infection Control Meetings. Director B confirmed the facility did not conduct Infection Control Meetings in 2021, one meeting held 5/11/22 and no meetings had been held in 2023.

Review of the Antimicrobial Stewardship Committee Agenda dated 2/8/23, 3/29/23, 4/19/23, 8/30/23 and 10/4/23 indicated Licensed Staff P was a committee member and the agenda indicated Licensed Staff P's titles were Employee Health Nurse/Infection Preventionist.

During a concurrent interview and document review, on 11/16/23 at 12:00 p.m., Administrative Staff Q confirmed Licensed Staff P's personnel file did not contain a job description for Infection Preventionist and did not contain an annual personnel review related to Infection Prevention. Administrative Staff Q stated Licensed Staff P's job duties were identified as the Employee Health Nurse part time and surveillance part time.

During a concurrent interview and document review, on 11/16/23 at 12:00 p.m., Licensed Staff P confirmed there was no job description developed related to Infection Prevention and Control duties. Licensed Staff P confirmed she did not have a performance evaluation related to Infection Prevention and Control duties.

Review of the governing body minutes for 2023 did not indicate the governing body had appointed Licensed Staff P as the Infection Preventionist.