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Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that psychiatric patients were safe from ligature risks and the appropriate level of patient safety monitoring was in place for suicidal patients. This potentially places all current and future suicidal patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that patient rooms on the Behavioral Health Units were free from ligature risks to prevent harm to the patients. (A 144-A)

2. The Hospital failed to ensure that physician ordered safety monitoring checks were performed every 15 minutes, as required by policy. (A 144-B)

An Immediate Jeopardy (IJ) began on 11/12/18 (date of Hospital's identification of ligature risks), due to the Hospital's failure to ensure that all Behavioral Health Units were free from ligature risks, and failed to ensure that patient safety monitoring checks were done as required, thus placing all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 3/29/19 at 1:45 PM, during a meeting with the Chief Medical Officer, Manager of Clinical Excellence, Quality Project Specialist, and President of the Hospital. The IJ was not removed by the survey exit date of 3/29/19.

A. Based on document review, observation, and interview, it was determined that for 3 of 3 Behavioral Health Units (5 East, 5 West and 5 Center), the Hospital failed to ensure that patients' rooms were free from ligature risks. This could potentially affect any current and future patients on the units who become suicidal (22 suicidal patients on census 3/28/19).

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08,2017, reviewed on 3/28/18 at approximately 2:00 PM included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails...pipes...bedsteads...door frames...handles, hinges and closures. Attachment A - Advanced Copy... Environmental Safety Risks...Ligature risk include but not limited to, hand rails, door knobs, door hinges...exposed plumbing...power cords on medical equipment"

2. The Hospital's policy titled, "Patient Rights and Responsibilities as a Patient at Advocate Health Care," (last review date by Hospital 3/14/2018) was reviewed on 3/28/19 and included, "As an Advocate patient, it is your right...2. To receive care that...personal privacy and safety..."

3. The Hospital's Accrediting Organization (AO) alert report entitled, "ALERT - Investigation Report of IJ at [Advocate Lutheran General Hospital]," dated March 27, 2019, was reviewed on 3/28/19 and included, "...Nonconformity was identified with ligature risk throughout the adult unit patient bathrooms including, but not limited to, faucets, hospital beds with siderails, bed frames and crank for raising and lowering beds. The Hospital confirmed the patient rooms, bathrooms and furnishings are the same for the Behavioral Health adolescent and geriatric units."

4. On 3/28/19 between 9:30 AM and 10:45 AM, an observational tour of the 5 East geropsychiatric (treating psychiatric disorders of patients older than 62) was conducted. The 5 East Unit had eight (8) patient rooms, each with a bathroom in it, that were set up identical and the following ligature risks were identified:
Each room consisted of a crank style bed, with full length side rails, that could be moved across the floor. There were two movable chairs in each room. The call light cord was zip tied to the bed side rail.
Each bathroom had a horizontal grab bar the length of the side wall, approximately 3 feet off the floor. The sink had a curved water faucet with separate handles to control hot and cold water. The toilet had metal pipes behind the bowl for water flow.
The two shower rooms (community shower rooms) in the hallway contained a horizontal grab bar on one side wall. The inside door closure was a door knob.

5. On 3/28/19 between 9:34 AM and 11:00 AM, an observational tour was conducted on the Adult Behavioral Health Unit (5 Center). The unit consisted of a total of 14 patient rooms with a total of 26 beds. The following ligature risks were identified:
Seven of the 14 rooms included, sliding bathroom doors with triangular loops for a pull handle, all of the rooms included a toilet with exposed pipes approximately 3 feet in length, leading into the wall.

Room #517's bathroom had a solid wood door that met flat against the solid metal frame, creating a ligature risk at the top when the door was closed. There were 2 protruding knobs, creating ligature points, an overhanging sink (not flush to the wall), with 2 knobs, a faucet, exposed pipes, and an overhanging shelf, creating a ligature risk, and a shower that contained a protruding control knob and a slanted grab bar with space between the bar and the wall.

Of the 26 patient beds, all were rolling that had open side rails, a head board, foot board, and 3 cranks (used to adjust height of bed), moveable furniture, which could potentially be used for patients to reach the top of door/door frame for hanging.

6. On 3/28/19 between 1:40 PM and 2:10 PM, an observational tour was conducted on the 5 West Pediatric (ages 8-18) Psychiatric Unit.
There were six semi-private rooms that were identical:
Each room had a bathroom, that had a horizontal grab bar the length of the side wall.
Each room contained two crank style beds on wheels with full side rails, two wooden desks that could be moved and two weighted (heavy) chairs that could be moved.

7. On 3/28/19 at approximately 1:30 PM, the Hospital presented the "Behavioral Health Design Details - Confirming Room Risk Levels," dated January 25, 2019. The plan identified ligature risk identified throughout the Hospital.

8. On 3/28/19 at approximately 2:00 PM, the Hospital presented the Hospital's Ligature Free Action plan dated 11/12/18. The plan included, "Commencement of the Project - Preliminary site observation walk through, dated November 27, 2018...Construction begins July 28, 2019."

9. On 3/19/19 Pt #1 was admitted to the 5 Center Inpatient Psychiatric Unit, with a diagnosis of major depression. The clinical record contained a physicians's admitting orders that included that Pt #1 be placed on suicide precautions with safety monitoring every 15 minutes. Pt #1 hung himself by attaching a cord from his CPAP machine to the toilet piping and expired at 6:55 AM.

10. On 3/29/19 at approximately 1:15 PM, an interview was conducted with the Assistant Nurse Manager (E #7). E #7 stated that patients have access to their rooms anytime and when they are in the bathroom, the staff are to visualize the patient. E #7 stated that the video surveillance does not record, it is monitored by the unit staff to monitor patients and areas mostly at night or at quieter times, staff will still do the 15 minute rounding. The 15 minute monitoring/rounding is done by the staff that is assigned for that shift. During the day, there is one staff doing the 15 minute rounding and at night there are two staff assigned to do rounding. The staff that are assigned to round are expected to visualize the patient, document location and behavior. If a patient is in the bathroom, staff is expected to knock on the door and listen for a response, if no response, staff should open the door. Patients do not need to ask for permission to use their bathroom. If a patient is at high risk and on 1:1, the sitter is with the patient at all times.

11. On 3/29/19 at approximately 1:15 PM, during the simultaneous interview with E #1 and E #7, the Manager of Clinical Excellence (E #1) stated, "The night shift data collection tool has been created and will involve both real time observations and monitoring of the rounding sheets. We require all staff to visually see the patient while doing rounds and if the patient is in the bathroom we knock on the door and wait for an answer. We leave patient doors open when the patients are out, allowing for freedom to return to their rooms when they want."

B. Based on observation, document review and interview, it was determined that for one (Pt. #1) of 5 patients reviwed for saftey monitoring, the Hospital failed to ensure physician ordered safety monitoring checks were performed every 15 minutes, as required by the plicy. This has the potential to affect all 22 patients on the Behavioral Health Units.

Findings include:

1. The clinical record of Pt #1 was reviewed on 3/28/19. Pt #1 was a 55 year old male who was admitted to the 5 Center Inpatient Psychiatric Unit on 3/19/19, with a diagnosis of major depression and a history of OSA (obstructive sleep apnea - temporary cessation of breathing, especially during sleep) on CPAP (Continuous positive airway pressure - keeps airway open). The Lutheran General Hospital Suicide Risk Assessment (last revision date 1/2019), was completed by the admitting RN and co-signed by a Licensed Clinical Social Worker (LCSW), and included, "Patient is at risk for suicide, however the patient does not present with serious suicidal ideation requiring 1:1 continuous monitoring at arms length in the current setting."
A physician's order dated 3/19/19, included, "Suicidal Precautions: Every 15 minute safety checks." The clinical record contained suicide assessments every shift, as required.

Pt #1's clinical record lacked documentation of every 15 minute safety checks for March 21, 2019 for suicide precautions from 5:45 AM and until the patient was coded at 6:45 AM. The patient hung himself by attaching a cord from his CPAP machine to the toilet piping and was pronounced expired at 6:55 AM.

2. The Hospital presented a document titled, "Fact Finding from Interviews and Investigation," and included, "...3/21/19 at 5:45 AM, MHC (Mental Health Counselor) completes safety rounding. 3/21/19 at 6:00 AM, MHC communicates to RN, that 5:45 AM patient safety rounding completed and moving on to next task....3/21/19 at 6:01 AM, RN checks blood sugar for 3 diabetic patients. 3/21/19 at 6:20 AM, RN knocks on patient door and hears no response, enters room to look for patient. Patient not found in bed. Bathroom door found partially closed with lights off. RN thinks patient may be in day room having coffee. RN looks for patient in day room. 3/21/19 at 6:25 AM, RN did not find patient in day room and returns to patient room. Checks bathroom and finds patient with power cord from patient's CPAP around neck and tied to toilet...Code Blue called."

3. The Hospital's policy entitled, "Suicide Precautions/High - Risk Suicide Precautions/Self - Wounding/Harm (without Suicidal Intent) Precautions", (Last Review Date 1/14/19) included, " ...F. An order for 'Suicide Precautions' must be obtained from an Attending Psychiatrist. This order specifies the following: 1. Unit team members shall check the patient as frequently as necessary, but not less than every 15 minutes ...3. At night times patients are asleep in their rooms, they will be checked at a minimum of every 15 minutes ..."

4. During the tour of 5 East, on 3/28/19 at 10:10 AM, the Assistant Manager (E#2) was interviewed. E#2 stated that all patients are placed on every 15 minute checks upon admission for 48 hours automatically. A suicide risk assessment is completed on admission by a registered nurse (RN). Depending on the answers to the questions, the RN uses their judgment to decide if patient is at high risk for suicide ideation, and gets the physician's approval for suicide precautions. The patient is placed with a 1:1 sitter, if deemed at high risk. Routine suicide precautions consist of every 15 minute safety checks. All patients can be a suicide risk, without 1:1, if no serious ideation or if the suicide plan is impossible to perform in the hospital setting (i.e.: overdose on pills, jump off a bridge). After 48 hours, if no precautions are required, the safety checks continue every 30 minutes for remainder of hospitalization.

The unit Manager (E#3) was interviewed on 3/28/19 at 2:00 PM. E#3 stated that all patients are placed on suicide precautions based on history. Patients are placed on 1:1 precautions if they are sexually acting out or in an active psychosis (disruptions to thought process in determining what is real and what isn't). Their rooms are also made single patient rooms. While in the room, the patient is monitored by the staff member assigned, at all times. The staff accompany the patient to the day room, toilet, and or shower.

5. On 3/29/19 at approximately 1:15 PM, an interview was conducted with the Assistant Nurse Manager (E #7). E #7 stated that all patients are to be assessed and monitored every 15 minutes. E #7 stated that unfortunately for this patient (Pt #1), adequate monitoring did not occur.