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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 environmental hazards. 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 patients. (A144-A).

2. The Hospital failed to ensure that physician orders included the level of severity for suicide precautions. (A144-B).

3. The Hospital failed to ensure that environmental rounds on the Behavioral Health Units were conducted. (A144-C).

4. The Hospital failed to ensure that patient rooms on the Behavioral Health Units were free from environmental hazards and contraband. (A144-D).

An Immediate Jeopardy (IJ) began on 2/26/18 (date of Hospital's ligature risk assessment), for the Hospital's failure to remove ligature risks and conduct environmental rounds, thus placing all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 3/12/19 at 10:00 AM, during a meeting with the Chief Operating Officer, Chief Compliance Officer, Vice President of Facilities, Design and Construction, Executive Director of Facilities, Design and Construction, Chief Nursing Officer, Assistant Director of Clinical Effectiveness, Program Director of Synergy (Behavioral Health), President/Chief Executive Officer, Executive Director, and the Regulatory Compliance Manager. The IJ was not removed by the survey exit date of 3/12/19.

A. Based on document review, observation, and interview, it was determined that for 5 of 5 Behavioral Health Units (1 North - Adult, 1 South - Adolescent, 1 Central - Geriatric, 2 B - Adult, and 2 C - Adult Step Down), the Hospital failed to ensure that patients' rooms were free from ligature risks. This has the potential to affect the safety of all 55 patients requiring suicide precautions on census in the Behavioral Health Units, as of 3/11/19, and any future patients who become suicidal.

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06- Hospitals (dated 12/8/17), was reviewed on 3/11/19, and 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...door frames...hinges ..."

2. The Hospital's policy titled, "Patient Rights and Responsibilities" (approved 4/12/18), was reviewed on 3/11/19. The policy required, "Personal Safety: The patient has the right to expect personal safety, insofar as the Hospital practices and environment are concerned."

3. On 3/11/19 at 9:30 AM, observational tours were conducted on 5 of 5 Behavioral Health Units (1 North - Adult, 1 South - Adolescent, 1 Central - Geriatric, 2 B - Adult, and 2 C - Adult Step Down). There were 55 patients on census across all 5 units. All 55 patients were on suicide precautions. Multiple ligature risks were identified as follows:

- Each patient room entry door was composed of solid wood that met flat against the solid metal frame, creating a ligature risk at the top when the door was closed. Entry room doors were unlocked and were able to be opened and closed by the patients. Patient rooms (40 total) included:

- 1 North: Rooms: 177, 179, 181, 183, 185, 187, 189, 191, 193, 195, 197;

- 1 South: Rooms: 145, 147, 149, 151, 153, & 155;

- 1 Central: Rooms: 157, 159, 161, 163, 165, & 167;

- 2 B: Rooms: 253, 255, 257, 259, 261, 263, 265, 267, 269, & 271;

- 2 C - Rooms: 239, 241, 243, 245, 247, 249, & 251.

- Each patient room entry door also had 3 solid, protruding metal hinges, creating a ligature risk.

- Each patient room had an unlocked solid bathroom door meeting a solid frame and 3 protruding door hinges, creating a ligature risk. Room 187 on 1 North had 2 bathrooms making a total of 41 affected bathroom doors.

- Each bathroom sink had solid, protruding faucets and handles, creating a ligature risk.

- Each bathroom shower had solid, protruding water flow/temperature handle, creating a ligature risk.

-1 North Rooms 177 - 1, 177 - 2, 181 - 2, 183 - 2, 187 - 1, 191 - 1, and 195 - 2 had medical beds with power cords and moveable side rails with openings, which could be used for hanging by the patients on the unit.

-There were moveable chairs in 1 North rooms 179, 183, and 197, which could potentially be used for patients to reach the top of door/door frame for hanging.

4. The Hospital's Behavioral Health Risk Assessment (dated 2/26/18), was reviewed on 3/12/19, and indicated that the Hospital identified the ligature risks present in patient bedrooms and bathrooms on the behavioral health units during their assessment in February 2018.

5. On 3/11/19 at approximately 11:10 AM, an interview was conducted with the Behavioral Health Nurse Manager (E#2). E#2 stated that she had been informed last Thursday (3/7/19), during an AO (accrediting organization) survey, that the AO had identified ligature risks on the behavioral health units. E#2 stated that an environmental risk assessment was also conducted sometime last year (in 2018) which identified these ligature risks. E#2 stated that no changes to the patient observations have been made, and that no physical changes had been made on the units regarding ligature risks following these assessments. E#2 stated that E#2 has not yet been directed by Administration to make any changes following the 3/7/19 survey. E#2 stated that staff are educated on suicide precautions upon hire and refreshed periodically; however, there has not been any staff re-education regarding precautions, suicide risk assessments, or ligature risks since 3/7/19.

6. On 3/11/19 at approximately 11:18 AM, an interview was conducted with the Director of 1 North (E#4). E#4 stated that no mitigation plan for the ligature risks, which were identified during the AO survey on 3/7/19, had been reviewed with E#4 as of 3/11/19. E#4 stated that no changes had been implemented regarding ligature risks or patient observations in the past year.



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B. Based on document review and interview, it was determined that for 15 of 15 (Pts. #4-18) clinical records reviewed for patients on suicide precautions, the Hospital failed to ensure that the physicians' orders included the level of intensity for suicidal precautions, in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Suicide, Homicide and Aggression Screening and Precautions" (approved 3/6/19), was reviewed on 3/11/19 and required, "...An order from an attending phychiatrist is needed to initiate suicide...precautions. Physician orders suicide precaution at a level of intensity deemed appropriate based upon assessment of the suicide risk. Nursing staff shall place the patient on a level of observation commensurate with the level of risk as ordered by the physician. a. Suicide Precaution: One to One Observation (severe) - The individual is considered actively suicidal. A dedication staff member is assigned to remain within arm's reach of the patient at all times. b. Suicide Precautions: Line of Site (moderate) - A staff member keeps the patient within visual observation at all times. The patient is not permitted to be in an area where staff is not able to directly see them. This intervention must be noted in the medical record and on the proper form. c. Suicide Precautions: 15 minute checks (mild) - Staff makes visual contact with the patient and confirms that the patient is safe and in no physical distress at frequent...random interval not to exceed fifteen (15) minutes apart..."

2. The clinial records for 15 patients (Pts. #4-18) on suicide precautions (SP) were reviewed on 3/11/19 and included:

- Pt. #4 was a 45 year old male, admitted on 2/22/19, with a diagnosis of schizophrenia (a mental disorder characterized by a disconnection from reality). Physician's orders, dated 2/22/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #5 was a 22 year old male, admitted on 2/27/19, with diagnoses of schizophrenia and delusional thoughts (a mental disorder where a belief or altered reality is held despite evidence or agreement of the contrary). Physician's orders, dated 2/27/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #6 was a 57 year old female admitted on 2/27/19, with diagnosis of psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), delusions, and hallucinations (unreal experience and sensation made up by the mind). Physician's orders, dated 2/27/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #7 was a 20 year old female, admitted on 3/5/19, with a diagnosis of psychosis. Physician's orders, dated 3/5/19, included suicide precautions (SP) but lacked the appropriate level of intensity of the SP.

- Pt. #8 was a 38 year old female, admitted on 3/6/19, with a diagnosis of manic depressive disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Physician's orders, dated 3/6/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #9 was a 58 year old female, admitted on 3/8/19, with a diagnosis of psychosis. Physician's orders, dated 3/8/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #10 was a 40 year old male, admitted on 3/5/19, with a diagnosis of manic depressive disorder. Physician's orders, dated 3/5/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #11 was a 45 year old male, admitted on 3/9/19, with a diagnosis of manic depressive disorder. Physician's orders, dated 3/9/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #12 was a 45 year old male, admitted on 3/9/19, with a diagnosis of manic depressive disorder. Physician's orders, dated 3/9/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #13 was a 45 year old male, admitted on 3/9/19, with a diagnosis of manic depressive disorder. Physician's orders, dated 3/9/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #14 was a 33 year old male, admitted on 2/28/19, with a diagnosis of schizophrenia. Physician's orders, dated 2/28/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #15 was a 46 year old female, admitted on 3/6/19 with a diagnosis of schizophrenia. Physician's orders, dated 3/6/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #16 was a 20 year old male, admitted on 3/6/19, with a diagnosis of psychosis. Physician's orders, dated 3/6/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #17 was a 21 year old male, admitted on 3/7/19, with a diagnosis of schizophrenia. Physician's orders, dated 3/7/19, included SP but lacked the appropriate level of intensity of the SP.

- Pt. #18 was a 21 year old male, admitted on 3/1/19 with a diagnosis of schizophrenia. Physician's orders, dated 3/1/19, included SP but lacked the appropriate level of intensity of the SP.

3. On 3/11/19 at approximately 11:18 AM, an interview was conducted with the Director of 1 North (E#4). E#4 stated that the level of severity of the SP is determined by the psychiatrist and should be included in the orders for SP.


C. Based on document review and interview, it was determined that for 5 of 5 (1 North, 1 South, 1 Central, 2 B, and 2 C) behavioral health units, the Hospital failed to conduct environmental rounds daily to ensure the safety of patients at risk for serious harm or suicide, in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Suicide, Homicide and Aggression Screening and Precautions" (approved 3/6/19) was reviewed on 3/11/19 and required, "...Safety Attendant or qualified personnel performs an environmental assessment at the beginning of each shift and after visitors leave to ensure no contraband has been brought..."

2. The Hospital's procedure titled, "Environmental and Safety Rounds" (undated) was reviewed on 3/11/19 and included, "Environmental and Safety Rounds take place from 2:00 PM - 3:00 PM daily as well as when needed.

3. The "Behavioral Health Environmental Rounds Forms" binders (from 3/1/19 - 3/10/19) were reviewed on 3/11/19 for 1 North, 1 South, 1 Central, 2B, and 2C. The binder on 1 North lacked completion of environmental rounds on 3/2/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/8/19, 3/9/19, and 3/10/19. The binder on 2 C lacked completion of environmental rounds on 3/1/19, 3/4/19, 3/5/19, 3/6/19, 3/8/19, 3/9/19, and 3/10/19. The environmental rounds forms dated 3/3/19 and 3/7/19 lacked completion of contraband checks for each room and common area. The binders on 1 South, 1 Central, and 2 B lacked completion of any environmental rounds from 3/1/19 through 3/10/19.

4. On 3/11/19 at approximately 11:18 AM, an interview was conducted with the Director of 1 North (E#4). E#4 stated that the environmental rounds should have been completed daily.

5. On 3/11/19 at approximately 11:10 AM, an interview was conducted with the Behavioral Health Nurse Manager (E#2). E#2 stated that the environmental rounds should be done daily by the day shift Behavioral Health Technician.




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D. Based on document review, observation and interview it was determined, that for 1 of 12 patient rooms observed on the 1 South (Adolescent Behavioral Health Unit) for contraband, the Hospital failed to ensure that staff completed environmental rounds to ensure patient rooms were safe and free from hazards. This failure put all 11 suicidal patients and all future patient on the 1 South Unit at risk for serious harm.

Findings include:

1. On 3/11/19, the Hospital policy titled, "Suicide, Homicide and Aggression Screening and Precautions" (dated 3/6/19), was reviewed. The policy included, " ...Anything that can be potentially used by patients to harm themselves or others is considered contraband and is not permitted. The items listed below are examples of contraband...Sharp objects ...hard plastics or other objects that may cut or puncture ..."

2. On 3/11/19 from 9:35 AM - 10:00 AM, an observational tour was conducted on the 1 South (Adolescent Behavioral health Unit). There were 11 patients on the census, and all were on suicide precautions. Patient room 151's bedroom and bathroom doors were open and unlocked. There was a loose, easily detached and readily accessible piece of ceramic floor tile with sharp edges on the bathroom floor.

3. On 3/12/19 at 9:18 AM, an interview was conducted with the Director of Behavioral Services (E#6). E#6 stated that the loose floor tile could be used by a patient to hurt themself.