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

A-0144 PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patient safety by failing to prevent high-risk suicidal patients from accessing contraband (potentially harmful items) for two of two patients reviewed who were actively suicidal and were found with unsupervised contraband. (Patient #3 and #4). In addition, the facility failed to monitor patients in accordance with facility policy in four of four high-risk patients being monitored via video cameras. (Patients #1, #4, #7, and #10)

Based on observations, interviews, and document review, the facility failed to ensure patient safety by failing to prevent high-risk suicidal patients from accessing contraband (potentially harmful items) for two of two patients reviewed who were actively suicidal and were found with unsupervised contraband. (Patient #3 and #4). In addition, the facility failed to monitor patients in accordance with facility policy in four of four high-risk patients being monitored via video cameras. (Patients #1, #4, #7, and #10)

Findings include:

Facility policies:

According to the Assessment and Care of the Suicidal Patient Policy, patients assessed to be at high risk for suicide will have 1:1 direct patient observation by qualified personnel with the ability to immediately intervene, potential safety hazards identified and removed from the patient's environment, and the staff will assess the patient's environment for further restrictions. 1:1 direct observation should be in person, with a direct line of sight and no competing responsibilities. Remote, virtual, or camera monitoring does not meet the requirements for 1:1 direct observation.

According to the Considerations for Referral, to Behavioral Health, Behavioral Health Holds, Elopement Precautions, and At-Risk Precautions Operational Work Flow Policy, patients' belongings are removed from the patient room, labeled, and searched by security. Nursing staff documents the safety reasons for the removal of the patient's belongings in the electronic health record (EHR). Additionally, the policy states the patient is changed into green scrubs, hospital socks, and a green wristband for safety and identification of high risk for safety.

1. The facility failed to search the belongings of suicidal psychiatric patients admitted to care unit 4 in the ED (ED).

A. Medical record reviews revealed items identified as contraband were not removed from patients considered to be at high risk of self-harm.

i. Review of Patient #3's medical record revealed he presented to the ED on 9/25/23 at 6:04 a.m. Patient #3 was diagnosed with suicidal ideation (thoughts of ending one's life) and alcohol intoxication (excessive amounts of alcohol in the bloodstream). Patient #3 was found to be a danger to himself and placed on an M1 hold (an involuntary 72-hour emergency mental health hold placed on a patient determined to be at risk of self-harm, harming others, or gravely disabled). According to the patient belongings flowsheet at 6:14 a.m., no personal belongings or shoes were inventoried for Patient #3. Further review of Patient #3's medical record revealed at 6:34 a.m., the Columbia-Suicide Severity Rating Scale (suicide risk assessment to identify someone at risk for suicide) was performed. The patient was deemed a high risk for suicide at that time. According to Patient #3's medical record, at 11:48 a.m., Patient #3 informed staff that his "shoes with the strings" were in his room. Further review of Patient #3's medical record revealed at 11:48 a.m., five hours and 25 minutes after Patient #3 was admitted, a security officer removed Patient #3's shoes and laces from the patient's room.

ii. Review of Patient #4's medical record revealed he presented to the ED on 6/22/23 at 5:45 p.m. with a diagnosis of suicidal ideation and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). According to the ED Triage Note entered at 5:53 p.m., Patient #4 was placed on an M1 hold for suicidal ideation due to statements of suicide and self-harm made at an outpatient appointment. According to the ED Triage Note, Patient #4 verbalized that he wanted to hang himself. ED Notes entered at 6:13 p.m., 28 minutes after Patient #4 presented to the ED, behavioral health specialist (BHS) #2, documented Patient #4 had a belt around his neck. According to the note, BHS #2 removed the belt and a hoodie after the items were identified.

The medical record review of Patient #3 and Patient #4 was in contrast to The Considerations for Referral, to Behavioral Health, Behavioral Health Holds, Elopement Precautions, and At-Risk Precautions Operational Work Flow Policy, which read patient's belongings were to be removed from the patient room, labeled, and searched by security. Additionally, nursing staff were to document the safety reason for removing the patient's belongings in the EHR.

B. Interviews

i. On 10/23/23 at 1:48 p.m., an interview was conducted with BHS #1. BHS #1 stated when a patient was placed in CU4, security would take the patient's belongings, log them, and place them in a locker located on the unit. BHS #1 stated patients on CU4 were asked to change into green scrubs (clothing designed specifically for use with patients at high risk of self-injury) for safety and identification purposes. BHS #1 stated staff documented if the patient refused to change and the reason why in the electronic medical record.

This was in contrast to the medical record review of Patient #4, who was wearing his own clothes and was not documented as having refused to change into the green scrubs

ii. On 10/18/23 at 9:05 a.m., an interview was conducted with security officer (Officer) #4. Officer #4 stated security on the CU4 unit was expected to take the patient's belongings, log them, and place them in a locker located on the unit. Officer #4 stated it was recommended that the patient change into green scrubs and remove their belt, shoes with laces, and any jewelry. Officer #4 stated sometimes the nurse did not change the patient into green scrubs because the nurse was concerned that the patient may become upset and combative.

iii. On 10/17/23 at 4:37 p.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated when patients arrived at CU4, the patients underwent a security check using a metal detector wand (a handheld device used to detect metal) and a pat down (passing the hands over someone's clothing to search for concealed items). RN #3 stated the purpose of the security check was to check for high-risk items such as drugs, weapons, or any object that could cause harm to the patient or those around them. RN #3 stated failing to identify and remove high-risk items could result in harm to the patient and staff.

iv. On 10/23/23 at 3:27 p.m., an interview was conducted with ED nurse manager (Manager) #5. Manager #5 stated it was security's responsibility to search all patients thoroughly. Manager #5 stated if the nursing staff found contraband in the patient's room after security performed their search, the nursing staff were expected to complete an incident report (internal report of safety concern used to collect data to improve patient safety and quality of care). Manager #5 stated it was necessary to screen and remove contraband for the safety of the patients and staff.

The documentation review and interviews conducted with CU4 staff BHS #1, RN #3, Officer #4, and Manager #5 were in contrast to the Considerations for Referral, to Behavioral Health, Behavioral Health Holds, Elopement Precautions, and At-Risk Precautions Operational Work Flow Policy which read, patient's belongings were to be removed from the patient room, labeled, and searched by security. Nursing staff were instructed to document the safety reasons for the removal of the patient's belongings in the electronic health record (EHR). The policy required patients to wear green scrubs, hospital socks, and a green wristband indicating high risk for safety and identification purposes.

2. The facility failed to ensure patients considered to be at risk for suicide were monitored and provided 1:1 observations according to facility policy.

A. Observations

i. Observations conducted on 10/17/23 at 4:13 p.m. revealed Patient #7 and Patient #10 had been admitted to CU4 for suicidal concerns. During the observation, a security officer was observed performing video surveillance monitoring for both Patient #7 and Patient #10. Additionally, the security officer was observed monitoring sixteen additional locations outside of CU4. Furthermore, while conducting video monitoring of Patient #7 and Patient #10, the security officer engaged in 2-way radio communication with other security officers and continually documented the communications and additional surveillance being performed.

This was in contrast to the facility policy Assessment and Care of the Suicidal Patient Policy, which read video monitoring was not to take the place of 1:1 direct patient observations. Staff performing 1:1 direct observations were not to be engaged in other activities while performing direct patient observations.

B. Medical record reviews revealed Patient #1, Patient #4, Patient #7, and Patient #10 were considered to be at risk for suicide. However, staff did not provide 1:1 direct patient monitoring for the patients.

i. Review of Patient #4's medical record revealed he presented to the ED on 6/22/23 at 5:45 p.m. with a diagnosis of suicidal ideation and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). According to the ED Triage Note entered at 5:53 p.m., Patient #4 was placed on an M1 hold for suicidal ideation due to statements of suicide and self-harm made at an outpatient appointment. According to the ED Triage Note, Patient #4 verbalized that he wanted to hang himself. ED Notes entered at 6:13 p.m., 28 minutes after Patient #4 presented to the ED, behavioral health specialist (BHS) #2, documented Patient #4 had a belt around his neck. According to the note, BHS #2 removed the belt and a hoodie after the items were identified.

Further review of Patient #4's medical record revealed Patient #4 was not placed on 1:1 monitoring in the 28 minutes from when the patient was placed in Care Unit 4 (CU4) to when staff discovered a belt wrapped around Patient #4's neck.

ii. Review of Patient #1's medical record revealed Patient #1 was transferred from a drug detox center to the facility by emergency medical services (EMS) on 9/26/23 at 9:55 a.m. Patient #1 was diagnosed with suicidal ideation with hallucinations with plans to stab herself or overdose on heroin. Review of Patient #1's medical record revealed at 10:06 a.m., the Columbia-Suicide Severity Rating Scale was performed. The patient was deemed a high risk for suicide at that time and placed on line-of-sight observation via video monitoring under the supervision of a security officer. Further review of Patient #1's medical record revealed at 10:21 a.m., Patient #1 was placed on an M1 Hold as the patient continued to be an imminent danger to themself.

This was in contrast with the Assessment and Care of the Suicidal Patient Policy, which read, patients assessed to be at high risk for suicide will have 1:1 direct patient observation by qualified personnel with the ability to intervene immediately. Remote, virtual, or camera monitoring does not meet the requirements for 1:1 direct observation.

iii. Review of Patient #7's medical record revealed she presented to the ED on 10/17/23 at 10:16 a.m. Patient #7 had a diagnosis of suicidal ideation with an attempt to end her life earlier that morning. According to the ED Triage Note entered at 10:24 a.m., Patient #7 was placed on an M1 hold for suicidal ideation due to concerning statements Patient #7 made at an outpatient appointment. According to the ED Triage Note, Patient #7 verbalized her attempt to overdose on prescription medications. Further review of Patient #7's medical record revealed at 10:21 a.m., the Columbia-Suicide Severity Rating Scale was performed, and Patient #7 was deemed a high risk for suicide at that time. Review of Patient #7's medical record revealed on 10/17/23 at 12:42 p.m., the patient was placed on line-of-sight observation under the supervision of a security officer. Further review of the medical record revealed a Safe-T assessment (an evaluation to identify suicidal risk factors) on 10/17/23 at 2:37 p.m. deemed Patient #7 was a high risk for suicide and continued to receive line-of-sight observation under the supervision of a security officer.

iv. Review of Patient #10's medical record revealed on 10/17/23 at 11:50 a.m., Patient #10 was placed on an Involuntary Transportation for Immediate Screening hold (a temporary six hour involuntary hold used to transport and hold a patient until a health evaluation can be performed). At 12:51 p.m., EMS arrived to the ED with Patient #10. According to the ED Provider Note entered at 12:52 p.m., Patient #10 was involuntarily transported to the ED after Patient #10 verbalized to his outpatient psychiatrist he planned to end his life. According to the ED Provider Notes and the orders placed by Physician #6 at 1:01 p.m., Patient #10 was placed on CU4 for a behavioral health evaluation, and at-risk precautions were ordered.

Further review revealed at 4:56 p.m., Patient #10 was determined to be a danger to himself and was placed on an M1 hold. The facility was unable to provide evidence 1:1 direct patient observation and monitoring were performed for Patient #10.

C. Interviews

i. On 10/18/23 at 9:05 a.m., an interview was conducted with security officer (Officer) #4. Officer #4 stated security officers were stationed at the nurse's station to monitor video surveillance of the ten beds inside the unit and virtually monitored locations outside of CU4. According to Officer #4, security officers stationed on CU4 responded to and documented security communications throughout the facility. Officer #4 stated the use of video surveillance was used to monitor the patients in place of 1:1 bedside monitoring by staff.

This was in contrast to the facility policy Assessment and Care of the Suicidal Patient Policy, which read video monitoring was not to take the place of 1:1 direct patient observations. Staff performing 1:1 direct observations were not to be engaged in other activities while performing direct patient observations.

ii. On 10/17/23 at 4:37 p.m., an interview was conducted with RN #3. RN #3 stated patients who scored high on the Columbia-Suicide Severity Rating Scale would be placed under 1:1 observation. RN 3# also stated there should never have been an instance where a patient was left alone that was deemed high-risk. RN #3 expressed concerns about leaving a high-risk patient unsupervised, citing if left unsupervised, there was potential for the patient to harm themselves and carry out their suicide plan.

iii. On 10/23/23 at 3:27 p.m., an interview was conducted with nurse manager (Manager) #5. Manager #5 stated patients who were considered to be at high risk for suicide should have been closely monitored, with the ability to intervene immediately if necessary, in order to ensure their safety. Manager #5 stated staff used the term 1:1 observation and line of sight observation interchangeably. Manager #5 also stated her staff would require reeducation on the proper use and documentation of line of sight and 1:1 observations

The observations, medical record reviews, and interviews conducted with CU4 staff RN #3, Security Officer #4, and NM #5 were in contrast to The Assessment and Care of the Suicidal Patient Policy read, patients assessed to be at high risk for suicide would have 1:1 direct patient observation by qualified personnel with the ability to intervene immediately. Additionally, the policy read that 1:1 direct observation should be in person, with a direct line of sight and no competing responsibilities. The policy further instructed that remote, virtual, or camera monitoring did not meet the requirements for 1:1 direct observation.