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Based on observation of video surveillance, review of medical records and facility documents, and staff interview, it was determined the facility failed to ensure: 1) items identified on the BG unit Environmental Risk Assessment (ERA) as a risk to be thrown or used as a weapon are not available to patients (A0144); 2) rooms with items identified on the ERA as a risk to be thrown or used as a weapon are monitored as per facility policy (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

The IJ was identified on 5/31/24 at 2:15 PM and an acceptable IJ removal plan was received and verified on 6/3/24 at 12:03 PM. On 6/3/24, implementation of the IJ removal plan was verified during an on-site visit and included the following: a tour of the BG unit to confirm the chairs identified as a risk to be thrown or used as a weapon were removed, review of staff re-education sign-in sheets, review of updated ERA and policy, and staff interviews regarding the facility's process for monitoring the community rooms, and use of sturdy, non-liftable chairs on the unit. The IJ was lifted on 6/3/24 at 12:03 PM.

Cross Reference:
482.13(c)(2) - Patient's Rights: Care in a Safe Setting

Based on medical record review, staff interview, review of facility documents, and review of video surveillance, it was determined the facility failed to provide care in safe setting by: 1) ensuring that items identified on the Environmental Risk Assessment (ERA) as a risk to be thrown or used as a weapon are not available to at risk patients; 2) ensuring that rooms with items identified on the ERA as a risk to be thrown or used as a weapon are monitored as per facility policy; and 3) failing to ensure that measures are in place to mitigate areas of risk identified on the Safety Risk Assessment.

Findings include:

1) The BG Unit Environmental Risk Assessment (ERA) from 3/29/24, identified "chairs" as a risk, indicating they "should be sturdy and heavy as possible to minimize likelihood of patients throwing or using as a weapon."

The BG unit Patient Census for 5/30/24 identified five of 19 patients with a "H/O [History of] Aggressive Behavior." This was confirmed with Staff (S)3 on 5/30/24 at 2:21 PM.

The Information for Use (IFU) for the ModuMaxx Armless Activity Chair provided 5/31/24, states, " ...If additional weight is necessary, ModuForm's exclusive Ballast Access System can be easily added ...Features: Hollow Core that can Ballasted if Needed for Additional Security ..."

The Information for Use (IFU) for the Integra Chair provided on 5/31/24, states, " ...These good are sold by [company name] for institutional use only and not as consumer products. The design characteristics of this product are not intended to replace or substitute the need for necessary supervision or other necessary protective measures to protect those who may be at risk. ...It is the customer's responsibility to ensure that products purchased from [company name] and installed are suitable for the environment in which they are installed. ...".

On 5/29/24 at 11:07 AM, medical record review was conducted with S5 (Information Technologist). Patient (P) 1's medical record revealed he/she was admitted on 3/25/24 at 5:06 PM, with a diagnosis of schizoaffective disorder, and bipolar disorder. The Behavioral Health (BH) History and Physical (H&P) on 3/25/24 at 7:45 PM, stated, " ...Contributing Past Psychiatric History: History per patient and records; ...History of verbal and physical aggression; History of property destruction reported; History of physical aggression towards parents resulting in legal charges and history of physical aggression towards [facility name] staff. ...". The Attending BH Event Note on 5/16/24 at 5:42 PM, stated, " ...Dr. Strong security code was called for patient's agitation and aggression. As per nursing staff the patient was sitting calmly in day room when [he/she] suddenly unprovoked got up and punched another patient [patient initials] on the arm and attempted to threw [sic] a chair at peer [initials] which grazed [his/her] arm. Patient subsequently left the day room and pushed both hands against the day room window which ultimately broke. ..."

On 5/29/24 at 1:55 PM, a tour was conducted on the BG unit with S2 (Senior Vice President, Chief of Quality and Equity Officer), S3 (Director of Nursing) and S13 (Director of facilities). Both community rooms, room B031 (TV room) and room B021 (Day room) were observed. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms available to all patients. S9 (Licensed Practical Nurse) was observed using an Integra plastic chair while conducting patient monitoring.

On 5/30/24 at 10:35 AM, medical record review was conducted with S5. P4 was admitted on 5/9/24 at 1:08 AM, with a diagnosis of schizophrenia. The BH Event Note on 5/12/24 at 12:00 AM, stated, " ...Dr. Strong security code was called for patient's agitation and aggression. As per nursing staff the patient walked out of [his/her] room demanding discharge, verbally aggressive, punched plexiglass and threw chair on the window. Upon evaluation patient remained agitated, shouting racial slurs at staff, and was not re-directable. ..."

On 5/30/24 at 12:48 PM, time stamped video surveillance review of the "BG RN Desk" for P4 was conducted in the presence of S1 (Chief Nursing Officer), S2, S3, and S7 (Director of Security). The video did not contain any audio. Review of the video surveillance dated 5/11/24 revealed the following:

11:55 PM: A staff member is observed sitting in an office chair with wheels in front of the nurse's station. S3 confirmed that staff was monitoring the community rooms.

11:56 PM: P4 was observed to walk up to the nurse's station and punch the window. The staff member monitoring the community rooms was observed to stand up from the office chair with wheels and back away, leaving the chair unattended. P4 was then observed to pick up the office chair with the wheels and throw it. Pieces of the chair were seen to break off onto the floor.

On 5/30/24 at 1:00 PM, time stamped video surveillance review of the "BG RN Desk" for P1 was conducted in the presence of S1, S2, S3, and S7. The video did not contain any audio. Review of the video surveillance dated 5/16/24 revealed the following:

5:17 PM: One staff member was observed sitting in an office chair with wheels in front of the nurse's station. An unoccupied plastic chair was observed next to the staff member. The door for room B021 and B031 appeared to be open. S3 indicated the staff member observed was monitoring both community rooms.

5:20 PM: The staff member in the office chair with wheels was observed to stand up and walk behind the nurse's station. The two chairs were observed to be unoccupied. S3 confirmed no staff was observed to be monitoring the community rooms at that time.

5:24 PM: P1 was observed pacing the hallway, then grabbed the office chair with wheels and pushed it down the hallway. P1 is observed to shove P3, then proceeded to pick up a plastic chair and throw it at P3.

On 5/30/24 at 1:43 PM, a tour was conducted on the BG unit. Upon entering the unit, an unoccupied office chair with wheels was observed in front of the nurse's station, accessible to patients. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs, were observed in the community rooms.

On 5/31/24 at 10:40 AM, S13 indicated, the ModuMaxx armless activity chairs can be moved for infection control reasons and to be able to rearrange room.

On 5/31/24 at 11:04 AM, an interview was conducted with S12 (Mental Health Associate [MHA]). S12 stated when he/she is monitoring the community rooms, "I use one of the chairs from the nurse's desk, a computer chair." S12 indicated he/she was assigned to monitor the kitchen at the time of the incident with P1 on 5/16/24. S12 stated, "I was coming out of the kitchen and saw [P1] throw the chair, I tried to talk to [P1] but [P1] said the voices were telling [him/her] to hit people." S12 indicated in the past three to four months, he/she has observed two patients' lift the ModuMaxx armless activity chairs. S12 stated, "[patients name] picked up the chair and used it to work out."

On 5/31/24 at 1:12 PM a phone interview was conducted with S14 (Director of Special Operations), who indicated the Integra plastic chairs were bought so they can be moved for cleaning purposes and to have the ability to reconfigure the rooms. During this interview, S2 stated, "[Integra plastic chairs] can be thrown."

2) Facility policy titled, "Constant Observation and Levels of Observation Including Safety Watch (SW)" reviewed 8/22, states, " ...Policy: It is the policy of [facility name] to provide protection when a patient's behavior represents a danger to self or others. ...Levels of Observation: ...6. Monitor Patient Activity: Staff will monitor patients in hallways and community rooms. ..."

On 5/29/24 at 1:55 PM, a tour was conducted on the BG unit with S2, S3 and S13. Both community rooms, room B031 (TV room) and room B021 (Day room) were observed. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms available to all patients. At 2:00 PM, S9, confirmed a staff member must always be monitoring both rooms.

On 5/30/24 at 1:00 PM, time stamped video surveillance review of the "BG RN Desk" for P1, was conducted in the presence of S1, S2, S3, and S7. The video did not contain any audio. Review of the video surveillance, dated 5/16/24, revealed the following:

5:17 PM: One staff member was observed sitting in an office chair with wheels in front of the nurse's station. An unoccupied plastic chair was observed next to the staff member. The door for room B021 and B031 appeared to be open. S3 indicated the staff member observed was monitoring both community rooms.

5:20 PM: The staff member in the office chair with wheels, was observed to stand up and walk behind the nurse's station. Two chairs were observed to be unoccupied. S3 confirmed no staff was observed to be monitoring the community rooms at that time.

Video surveillance review of the "BG TV Room" for P1, dated 5/16/24, revealed the following:

5:24 PM: P1 was observed to enter room B031 and punch his/her peer in the right arm and exit the room. S3 confirmed no staff was observed to be present in room B031 during this time.

Video surveillance review of the "BG RN Desk" for P1 dated 5/16/24 revealed the following:

5:24 PM: P1 was observed pacing the hallway, then grabbed the office chair with wheels and pushed it down the hallway. P1 was observed to shove P3 then proceeded to pick up a plastic chair and throw at P3. S7 indicated P1 broke the window in room B021 at this time, although it is unable to be visualized by video surveillance.

On 5/30/24 at 1:43 PM, a tour was conducted on the BG unit. Upon entering the unit, an unoccupied office chair with wheels was observed in front of the nurse's station. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms. S2 indicated S11 (MHA) was assigned to monitor the community rooms. During an interview with S11, when asked if he/she was assigned to monitor the community rooms, S11 stated, "I am assigned to do the patient rounding." S11 was observed to be performing patient rounding at that time. S11 indicated all staff are aware that the community rooms have to be monitored but it is not on the assignment sheet, it is verbally discussed.

On 5/31/24 at 10:11 AM, in the presence of S1, S2, S3, S4, and S13, a discussion concerning monitoring of patients took place. S3 confirmed that all patients have access to the community rooms. S3 confirmed community room monitoring entails a staff member sitting outside the nurse's station, in the hallway between the community rooms, in order to be able to view both community rooms. S3 confirmed that staff are assigned to monitor the rooms with a verbal request and not officially assigned on schedule.

On 5/31/24 at 11:04 AM, an interview was conducted with S12 (MHA). S12 indicated the community rooms need to be monitored at all times. S12 stated, the monitoring is done by sitting in a chair in front of the nurse's station to be able to monitor the two rooms, as well as the hallways. S12 indicated the rooms needs to be monitored due to patients getting too close and kissing or hugging each other and the potential for violence in those rooms.

On 5/31/24 at 1:10 PM, when S2 was asked if the plastic chairs are approved to be on the behavioral health units, S2 stated, "the rooms need to be ligature resistant as long as the rooms are observed, we can have those chairs." S3 confirmed through unit observation and video surveillance, these rooms are not being monitored at all times.

3) On 5/30/24, a review of the Environmental Risk Assessment (ERA) dated 3/29/24, windows/glass was identified as a risk. The ERA reads, "Interior and exterior should not yield sharp shards of glass when broken that can be used as a weapon." The ERA states the location of these windows as, "Most exterior walls and interior doors." The ERA states, "Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient acuity."

During an interview at 11:15 AM, S13 (Director of Facilities), confirmed the ERA language from the 3/29/24 report is the same language that was included in the ERA that was in effect during the calendar year 2022 and 2023.

At 11:20 AM on 05/30/24, S13, states, "The safety tempered glass and wired tempered glass is being replaced with laminated glass because the windows are breakable, and glass falls out. We are replacing windows as they break."

A review of incident reports from 2023 and 2024, detailed the following incidents where windows were broken on the Behavior Health Units:

11/17/23, Unit BH-AG, P16, "Pt. witnessed by MHA banging on the window in [his/her] room with [his/her] plastic bed frame until the window glass got shattered. The patient was agitated and demanded discharge. Patient was noticed to having superficial abrasion to the right and left knuckles. ROC saw patient and ordered stat X-Ray which was negative for fractures."

02/21/24, Unit BH-BG, P15, "At around 6:20 PM, Patient started punching the ceiling without any provocation while standing on the table in the dayroom. Staff asked [him/her] to stop and then patient took out [his/her] shirt and postured that [he/she] was ready to fight to anyone. [He/She] then grabbed the chair and threw it twice to the window glass resulting to shattered glass. Dr. Strong was initiated, and restraint was ordered . . ."

04/28/24, on Unit BG-12A, P14, "Patient was found missing during 18:30 Headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing. Security and ADN were immediately notified. Security Officer said that the patient was in the ER. ROC was also notified."

5/16/24, on Unit BH-BG, P1, "...Pt [patient] hit and broke window with both hands. ...".

On 05/30/24 at 12:00 PM, a review of the window inventory for Unit BG, provided by the Director of Facilities, identified forty-one (41) as "safety Tempered" and nine (9) as "Wired Tempered."

On 5/30/24 at 4:29 PM, S7 (Director of Security), provided a picture of the broken window on Unit BG, from 5/16/24. The picture showed visible glass debris on the windowsill.


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