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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 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure a safe environment for patients in the psychiatric behavioral health unit (BHU). Specifically, patients in the BHU were able to access potentially dangerous items (contraband). The facility lacked policies, procedures, and or processes for staff to perform thorough environmental searches to ensure contraband was identified. Moreover, the facility failed to investigate contraband safety events and implement preventive measures to prevent recurrence. These failures were identified in one of one inpatient psychiatric units.

Based on interviews and document review, the facility failed to ensure a safe environment for patients in the psychiatric behavioral health unit (BHU). Specifically, patients in the BHU were able to access potentially dangerous items (contraband). The facility lacked policies, procedures, and or processes for staff to perform thorough environmental searches to ensure contraband was identified. Moreover, the facility failed to investigate contraband safety events and implement preventive measures to prevent recurrence. These failures were identified in one of one inpatient psychiatric units.

Facility findings:

Facility policies:

The Operational Workflow: Belongings Search, Documentation & Updates policy read, clothing that is unapproved for patient use on the unit are clothing items with strings, torn/soiled clothing, inappropriate/vulgar/graphic designs clothing, crop tops, and shorts of appropriate length, dresses/skirts, and winter jackets.

The Patient Safety and Visitor Searches policy read, prohibited items include any instrument, device, or item likely to cause death, injury, or a safety concern to patients, visitors, or staff. These items may include but are not limited to, sharp craft items (needles, latch hooks), other sharp items, and any other items identified by clinical staff to help ensure patient safety.

The Occurrence Reporting policy read, individuals who discover, witness, or become aware of the circumstances indicative of an occurrence (including actual, near miss, patient, visitor, employee injuries, and workplace violence events) complete an electronic occurrence report by the end of shift, which includes a brief factual description of the event. Definitions: Adverse Event: an event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. Occurrence: any event affecting the safety of an individual or facility, including any adverse event or near miss of an adverse event. An occurrence may or may not result in an injury, and may or may not involve error.

1. The facility failed to investigate adverse events (safety events) related to contraband, implement preventative measures to prevent recurrence and establish policies, procedures, and or processes for environmental searches conducted in the BHU to ensure psychiatric patients did not have access to contraband.

A. Document review revealed multiple contraband safety events occurred in the BHU between 1/12/24 and 4/24/24. Examples included:

i. Medical record review revealed Patient #9 was admitted to the BHU on 1/18/24 at 5:07 p.m. for suicidal ideation (thoughts of suicide) and planned to inflict life-threatening cuts to themselves.

On 2/12/24 a safety event occurred with Patient #9. Review of the safety event report entered at 3:20 p.m. revealed, 25 days after admission, Patient #9 cut their forearms with a piece of metal from a pen. Further review of Patient #9's medical record revealed a Significant Event Note entered at 4:00 p.m. which read, at the time of the safety event, Patient #9 was monitored one on one (continuous visual observation) by BHU staff.

ii. A review of Patient #5's medical record revealed, on 3/1/24 at 4:20 p.m., Patient #5 was admitted to the inpatient BHU with psychosis (disconnection with reality) and suicidal ideation. Patient #5 presented to the emergency department (ED) after admitting they wanted to harm another person and had been found by law enforcement officers holding a knife.

According to the Psychiatric Admission H&P entered at 5:40 p.m., Patient #5 heard voices telling them to kill themselves and Patient #5 wanted to end their life.

According to the safety event entered on 3/19/24 at 8:30 a.m., 18 days after Patient #5 was admitted, a behavioral health specialist (BHS) saw Patient #5 tying a thin rope around their waist. Patient #5 informed the BHS they used the rope as a belt and had been doing so since they were admitted to the facility on 3/1/24.

a. On 4/2/24 at 8:10 p.m., a similar safety event occurred with Patient #7. According to the safety event, BHU staff saw Patient #7 wearing sweatpants with a drawstring.

iii. A review of Patient #10's medical record revealed, on 3/21/24 at 12:32 a.m., Patient #10 was admitted to the inpatient BHU for suicidal ideation.

Upon review of the Daily Progress Note entered on 3/25/24 at 2:06 p.m., Patient #10 had thoughts of self-harm and increased suicidal thoughts.

According to the safety event entered at 4:48 p.m., Patient #10 had removed the bendable metal nosepiece from the face mask they were given in an attempt to self-harm.

a. A similar safety event occurred with Patient #14 on 4/23/24 at 9:13 p.m. Review of the safety event revealed BHU staff had found a facemask with a sharp bendable metal nosepiece in Patient #14's room.

Review of Patient #14's medical record revealed Patient #14 was admitted to the BHU for suicidal ideation on 4/22/24 at 2:59 p.m. According to the Psychiatry Progress Note entered at 8:44 p.m., Patient #14 was suicidal and had planned to cut themselves.

iv. A review of Patient #8's medical record revealed, Patient #8 was admitted to the BHU on 3/25/24 at 10:31 a.m. According to the Psychiatric Admission H&P, Patient #8 had suicidal ideation and a recent suicide attempt. Further review of the Psychiatric Admission H&P revealed Patient #8 had attempted to commit suicide by cutting their neck.

On 3/27/24, two days after Patient #8 had been admitted to the BHU, a safety event occurred with Patient #8. According to the safety event report, Patient #8 was found bleeding from a self-inflicted wound on their neck. Patient #8 had procured a paperclip and used the paperclip to self-inflict a laceration (a cut caused by a sharp object) to their neck.

After the safety event occurred, BHU staff conducted a contraband search in Patient #8's room and found a paperclip broken into two pieces, multiple nicotine patches (anti-smoking medication), and a piece of a glove.

a. A similar safety event occurred on 4/20/24 at 4:45 a.m. According to the safety event report, a patient on the BHU found a paperclip on the floor by the group room.

These events were in contrast to the Operational Workflow: Belongings Search, Documentation & Updates and the Patient Safety and Visitor Searches policies which read, patients were not allowed to have patient clothing items with strings and any item, instrument, or device that could cause death, injury, or pose a safety risk to on the unit.

B. Interviews with staff revealed staff had not been provided additional training and education after contraband had been continually identified on the BHU.

i. On 4/18/24 at 12:15 p.m., an interview was conducted with Behavioral Health Specialist (BHS) #3. BHS #3 stated staff conducted contraband searches as part of the environmental checks performed on the unit. BHS #3 stated environmental and contraband searches were performed when the patient was admitted, at the beginning of each shift, and whenever staff suspected patients had dangerous items.

BHS #3 stated staff conducted environmental checks and contraband searches to increase patient and staff safety. BHS #3 further stated environmental checks for contraband needed to be more consistent, as staff did not always conduct an environmental check during every shift.

BHS #3 stated nurses were informed when contraband was found during environmental checks. BHS #3 stated they were not aware a safety event should be completed when contraband was found on the unit and they had not been trained on how to enter a safety event.

ii. On 4/25/24 at 3:36 p.m. an interview was conducted with the supervisor of patient and milieu safety (Supervisor) #6. Supervisor #6 stated environmental searches were supposed to be performed at a minimum of once per shift. Supervisor #6 stated during the environmental searches staff looked for contraband.

This was in contrast to the interview with BHS #3 who stated staff did not always conduct an environmental check during every shift.

Supervisor #6 stated when contraband was found on the unit staff were to inform the supervisor or charge nurse and complete a safety event report. However, Supervisor #6 stated they were aware not all BHU staff knew how to complete a safety event.

iii. On 4/25/24 at 11:20 a.m., an interview was conducted with registered nurse (RN) #4. RN #4 stated staff needed to secure items considered to be contraband. RN #4 stated removal of contraband from the unit was important to ensure patients remained safe. RN #4 stated patients could use contraband to inflict physical injuries and even death to themselves and others.

RN #4 stated they were not aware staff were supposed to complete a safety event when contraband was found on the unit. RN #4 further clarified they had not completed a safety event when they identified contraband on the unit and thought safety events were completed based on whether the patient was able to harm themselves or other patients.

These interviews were in contrast to the Occurrence Reporting policy which read, a safety event was to be completed by staff for events that resulted in an actual injury, nearly resulted in an injury, or had the potential to result in an injury to a patient.

iv. On 4/30/24 at 1:01 p.m., an interview was conducted with nurse manager (Manager) #5. Manager #5 stated environmental checks were supposed to be performed twice a day, once on the day shift and once on the night shift. Manager #5 stated environmental checks were performed to identify and remove items that could be used by patients to self-harm or to harm others. Manager #5 stated during environmental searches, staff searched for contraband in patient rooms, restrooms, common areas, and hallways.

Manager #5 stated anytime staff found contraband on the unit a safety event report was to be completed. Manager #5 stated they were not aware some of the BHU staff did not know how to complete a safety event or when a safety event should be completed.

Manager #5 stated they reviewed and investigated the contraband safety events on the BHU. Manager #5 stated staff would be provided education about contraband on the unit after contraband events were reviewed. Manager #5 stated the purpose of the education was to reinforce the importance of keeping patients safe by not allowing patients access to items considered contraband. However, upon request, the facility was unable to provide evidence staff education had occurred.

On 4/25/24 at 12:47 p.m., upon request, the facility was unable to provide evidence of policies, procedures, and/or processes for staff to perform thorough environmental searches to ensure contraband was identified.

Furthermore, the facility was unable to provide evidence of contraband safety event investigations and any preventive measures implemented to prevent recurrence.