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Based on document review, interview, and observation, it was determined that the Hospital failed to ensure that the patient's rights were protected. This potentially affects current and future patients admitted to the Hospital's behavioral unit 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 provide care in a safe setting by failing to provide 1:1 observation and to complete observation rounds every 15 minutes, as required. See deficiency cited at A-144 A.

2. The Hospital failed to conduct suicide risk assessments, as required. See deficiency cited at A-144 B.

The Immediate Jeopardy (IJ) was identified on 7/12/2022, at 42 CFR 482.13, Patient Rights, due to the Hospital's failure to provide care in a safe setting by failing to ensure 1:1 observation and suicide risk assessments were completed for patients with suicidal ideation. The Immediate Jeopardy was announced on 7/12/2022 at 3:00 PM in a meeting with the President, the Chief Executive Officer, the Vice President of Quality and Compliance, and the Senior Vice President of Patient Care. The IJ was not removed by the survey exit date of 7/12/2022.

A. Based on document review, interview, and observation, it was determined that for 3 of 6 (Pt.#11, Pt.#24, and Pt.25) patients' clinical records reviewed for patients with suicide precautions, the Hospital failed to provide care in a safe setting by failing to provide 1:1 observation and to complete observation rounds every 15 minutes, as required. This failure is likely to cause serious harm, injury, or death to current and future suicidal patients in the Hospital.

Findings include:

1. On 7/07/22, the policy titled, "Precautions" (revised 3/22) was reviewed and required, "...Suicide ... Patients who have been assessed and evaluated who are determined to be at risk to harm themselves ... will be placed on suicide precautions 1:1 observation ... 1:1 observation means, the patient has a sitter with them at all times ... The Sitter is required to document what the patient is doing every 15 minutes on the Precaution sheet attached ..."

2. On 7/7/22 at approximately 10:30 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a direct admit to the Hospital's Medical/Psychiatric Unit on 6/30/22 at 3:04 AM and discharged on 7/4/22 at 4:30 PM. The clinical record included the following:

-Pt #11's History and Physical note, dated 6/30/22 at 4:50 AM, included, " ... (Pt.#11) with PMH (past medical history) of bipolar disorder ... presents as a direct admit from (name of hospital) with a petition that states 'Pt has a history of mental health issues, presented to the hospital after he admits he took 6 of his Effexor and 6 Risperdal in a suicide attempt' ... Currently pt states that he lied about taking the pills to seek attention. States he has never contemplated suicide ... Plan: ... Suicide attempt ... Continue home medications, 1:1 observation, Suicide precautions ... psychiatric consult..."

-Physician's order, dated 6/30/22 at 4:49 AM, included, "Suicide Precautions, 1:1 Observation Precaution". The clinical record did not include a Physician's order to discontinue Suicide Precautions or 1:1 Observation during Pt #11's admission.

-Admission Assessment note, dated 6/30/22 at 5:21 AM, included, "Risk for Suicide: The Sad Persons Scale for assessing the Risk for Suicide... Total Score: 4; Proposed Clinical Actions - 3 to 4 score, Initiate a 1:1 level of observation for the patient ..."

-Observation flow sheets were reviewed and indicated that the observation flow sheets were not completed as required as follows:
- 6/30/2022 from 6:00 AM to 6/30/2022 4:00 PM (10 hours).
- From 7/1/22 at 7:45 AM to 7/2/2022 at 11:00 PM (39 hours).
- There were no observation flow sheets completed for 7/3/2022 - 7/4/2022.
-BiPAP/CPAP (breathing apparatus with long plastic tubing) flow sheets, dated 6/30/2022 through 7/3/2022, were reviewed and indicated that Pt. #11 was placed on CPAP machine. (The BiPAP/CPAP's long tubing was a ligature risk, that could be used to hang oneself.)
-Hemodialysis Treatment Summary for 7/1/22, 7/2/22, and 7/4/22, were reviewed and indicated that (Pt. #11) received dialysis treatment in the dialysis treatment unit on these dates. (The hemodialysis needles could be removed easily by the patient and lead to hemorrhaging and death.).

3. On 7/12/2022 at approximately 9:33 AM, an interview was conducted with the Director of the Behavioral Health Unit (E #4). E#4 stated that when patients are on 1:1 precautions the staff should be within arm's length of the patient at all times.

4. On 07/7/22 at approximately 1:45 PM, an interview was conducted with the Senior Vice President of Patient Care (E#9). E#9 stated that all patients on special precautions, including 1:1 precaution, should have an observation flow sheet with documentation every 15 minutes. E#9 stated that the sitter cannot accompany the patient (Pt. #11) to the dialysis clinic because the clinic is a small area and there is not enough room for additional staff.

5. On 7/11/2022 at 2:04 PM, an interview was conducted with Pt. #11's Psychiatrist (MD #3). MD #3 stated that Pt. #11 was placed on 1:1 observation for three days, following the initial suicide risk assessment. MD #3 stated that Pt. #11 was high risk for suicide because Pt. #11 had a previous suicide attempt and had an active plan to overdose on pills. MD#3 stated that on 7/4/2022, the 1:1 observation was discontinued and Pt. #11 was placed on close observation.

6. On 7/12/22 between 9:30 AM to 10:20 AM, an observational tour of the Medical/Psychiatric Unit (3-East) was conducted. The Unit had a capacity of 41 and the census was 21. Staffing included four Registered Nurses (RN), four Nurse Technicians, and one Clerk. There was one patient with 1:1 observation precaution for suicidal ideation. Pt. #24 was in a room with the door closed due to respiratory isolation precaution. The sitter was sitting outside of Pt. #24's room and was observed opening the door to conduct the 15-minute observations.

7. The clinical record for Pt. #24 was reviewed on 7/12/22. Pt.#24 was admitted on 7/9/22 at 2:34 PM, with a diagnosis of COVID-19, and Major Depressive Disorder. The clinical record included the following:
-Physician's order, dated 7/9/22 at 5:05 PM, included, "Suicide Precautions, 1:1 Observation Precaution."
-Observation flow sheets, dated 7/10/22 through 7/12/22, were reviewed and indicated that the observation flow sheets were not completed as required on the following dates/times:
-From 7/9/22 at 5:00 PM to 7/10/22 at 6:45 AM (15 hours and 45 minutes).
-From 7/10/22 at 7:15 PM to 7/11/22 at 10:00 AM (14 hours and 30 minutes).

8. On 7/12/22 at approximately 10:10 AM, an interview was conducted with the Senior Vice President of Patient Care (E#9). E#9 confirmed that the clinical record for Pt. #24 lacked documentation for the observational precautions from staff.

9. On 7/12/2022 at 9:44 AM, an observational tour was conducted of the 4 south female Behavioral Health Unit. There were 14 patients being cared for by 2 Registered Nurses, 3 Mental Health Workers and 4 sitters. There were 4 patients on 1:1 observation precautions. At 9:44 AM, Pt. #25 (1:1 patient) was observed sitting in the front activity room with two other patients and one Mental Health Worker. At approximately 10:00 AM, with the Head of Security, the Director of Quality and Compliance (E#1), and the Director of the Behavioral Health Unit (E #4), videotape footage from camera 12, on the 4 south female Behavioral Health Unit, on 7/12/2022 from 9:00 AM - 9:40 AM was viewed and the following was observed:
Camera 12:
-At 9:03:25, Pt. #25 walked out of her room and down the hallway, without 1:1 staff observation.
-At 9:06:43, Pt. #25 walked down the hallway and back into her room, without 1:1 staff observation.
-At 9:12:14, Pt. #25 walked out of her room and down the hallway, without 1:1 staff observation.
-At 9:22:12, Pt. #25 walked back down the hallway past her room and then back down the same hallway past her room, without 1:1 staff observation.
-At 9:42, a sitter (E #15) was observed placing a moveable chair in Pt. #25 room, exiting the room and walking down the hallway. Pt. #25 was not seen with E #15.

10. On 7/12/2022, Pt. #25's clinical record was reviewed. Pt. #25 was admitted on 7/10/2022, to the female Behavioral Health Unit with a diagnosis of bipolar disorder. The suicide risk assessments, dated 7/10/22 and 7/11/2022, included, " ...The Sad Persons Scale for Assessing the Risk for Suicide - total score 3 ...Proposed clinical actions 3 to 4 - Initiate a 1:1 level of observation for the patient ..." The physician order, dated 7/11/2022, included an order for suicide precautions. The History and Physical progress note dated 7/10/2022, authored by MD #3), included, " ...Level of Observation - 1:1 suicide precaution ..."


B. Based on document review and interview, it was determined that for 2 of 6 (Pt.#11 and Pt.#24) clinical records reviewed for patients with suicide precautions, the Hospital failed to conduct a suicide risk assessment, as required, to ensure care was provided in a safe setting.

1. On 7/07/22, the policy titled, "Precautions" (revised 3/22) was reviewed and required, " ...Nurses, based on their assessment and evaluation of a patient's behavior and/or interactions with the patient may also recommend and institute precautions to ensure the safety ... the patient will be continually evaluated for the ongoing need for this intervention ..."

2. On 7/11/2022, the Hospital's policy titled, "Suicide Risk Screening Assessment and Intervention" dated March 20, 2022, was reviewed. The policy required, "...Nursing Procedures In-patient Units...2...the Admission Nurse on the unit must complete the Suicide screening and the Suicide Assessment found in the Admission Assessment and the Daily Focused Assessment Tab in the Electronic Medical Record (EMR)...3. The Daily Focused Assessment must be completed each shift and each day that the patient is Hospitalized by the Nurse assigned to the patient."

3. On 7/7/22 at approximately 10:30 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a direct admit to the Hospital on 6/30/2022, "Presents as a direct admit from (name of hospital) with a petition that states 'Pt has a history of mental health issues, presented to the hospital after he admits he took 6 of his Effexor and 6 Risperdal in a suicide attempt." The clinical record lacked documentation of a suicide risk assessment from 7/1/22 through 7/4/22.

4. The clinical record for Pt. #24 was reviewed on 7/12/22. Pt.#24 was admitted on 7/9/22 at 2:34 PM, with a diagnosis of COVID-19, and Major Depressive Disorder.
The clinical record lacked documentation of a suicide risk assessment from 7/9/22 through 7/11/22.

5. On 7/7/22 at approximately 1:45 PM, an interview was conducted with the E#9 (Senior Vice President). E#9 stated that patients on suicide precautions are required to have a suicide risk assessment every shift by the RN.