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Based on observations and interviews, the hospital failed to ensure the hospital was maintained in a manner to promote cleanliness in 2 of 3 Operating Rooms (OR) (OR#1 and #2) and 2 of 2 procedure rooms (Procedure Room #1 and #2).

Findings:

1. On 12/11/19 at approximately 9:35 AM, a three foot area of exposed sheetrock was observed in OR #1 behind a surgical table and a one foot area of chipped patient was observed in OR #2 behind a trash receptacle. The area of exposed sheetrock and chipped paint created a surface which could not be easily cleaned and sanitized. These findings were confirmed by the Director of Surgical Services and Quality Improvement Specialist at the time of the observation.

2. On 12/10/19 at 1:50 PM, visibly dusty wall vents were observed in Procedure Rooms #1 and #2. These findings were confirmed by the Director of Surgical Services and Quality Improvement Specialist at the time of the observation.

Based on record reviews and interviews, the Condition of Participation: Organizational Structure was not met as evidenced by the hospital's governing body failure implement a policy to ensure the safety of patients, assessed to be at risk of self harm, in 1 of 1 bathrooms in the Emergency Department (ED) utilized by patients assigned to the behavioral health (CH) area. This failure constituted a determination of immediate jeopardy (IJ) and the IJ was determined to be abated on 12/12/19.

Finding:

Standard: §§485.627(a) Standard: Governing Body or Responsible Individual also known as tag C-0241 - Based on observations, interviews, and record reviews, the facility's governing body failed to implement a policy to ensure the safety of patients, assessed to be at risk of self harm, in 1 of 1 bathrooms in the Emergency Department (ED) utilized by patients assigned to the behavioral health (CH) area. This failure constituted a determination of immediate jeopardy (IJ) and the IJ was determined to be abated on 12/12/19. Please see C-0241 for details.

The cumulative effect of this deficient practice resulted in this Condition of Participation being out of compliance.

Based on observations, interviews, and record reviews, the facility's governing body failed to implement a policy to ensure the safety of patients, assessed to be at risk of self harm, in 1 of 1 bathrooms in the Emergency Department (ED) utilized by patients assigned to the behavioral health (CH) area. This failure constituted a determination of immediate jeopardy (IJ) and the IJ was determined to be abated on 12/12/19.

Finding:

The ED has an area that is designated as the BH area and this area is comprised of a common room and two patient rooms. There is a security office is attached to the BH area and it has windows looking into the common room for surveillance and camera monitoring and there is a Nursing Station diagonally across which has limited view of the BH area. There is bathroom, that is located adjacent to the BH area that is utilized by all ED patients, including patients assigned to the BH area.

On 12/11/19 at 10:30 AM, surveyors observed ligature points in the common area and two patient rooms of the behavioral health (BH) area of the ED and bathroom utilized by patients assigned to the behavioral health area. The ligature points observed in the BH area included three door handles and four ceiling vent covers (two in the common area and one in each of the two patient rooms). The ligature points in the bathroom that was utilized by patients assigned to the BH area included gaps around the toilet plumbing, two open handrails on both sides of the toilet, the toilet paper dispenser, gaps around the sink, the sink faucet, three open handrails/grab bars in the shower, the shower head with hose, the shower seat, the door handle (door locks from within bathroom), the door arm, and the hinges. At the time of the observation, the Emergency Services Manager stated there is always monitoring of patients in the BH area at all times by staff and via camera. The Manager indicated that if security staff were pulled away from the security office another ED staff member was assigned to monitor the patients in the BH area.

On 12/11/19 at 11:30 AM, the Director of Quality provided an architectural plan, dated 10/23/19, outlining the ligature risks and the proposed fixes in the BH area and the bathroom. At 11:45 AM, the Director of Quality advised that it was confirmed with the Emergency Services Manager that a staff member always accompanies patients, identified as a safety risk, into the bathroom identified as having ligature points.

On 12/11/19 at 2:05 PM, surveyors observed the BH area door was wide open (door contains no lock), Patient #21 in the common area, and there was no Security Officer in the security office and an ED staff member was at the nurse station with limited view to the BH area.

Patient #21's record was reviewed. The patient had a diagnosis of Depression with Suicidal Ideation; had been assigned to the BH area since 12/9/19; and he/she scored "High Risk" on the Columbia Suicide Severity Scale. It was also noted that prior to admission, the patient had made a "purposeful suicide attempt".

On 12/11/19 at approximately 2:10 PM, the Security Supervisor was interviewed. He stated he was the only Security Officer on campus, at that time. When asked if he or any staff accompany patients from the BH area of the ED into the bathroom, he stated, he had not accompanied patients into the bathroom, nor was he aware of any security staff or ED staff member that accompanied patients into the bathroom. He stated sometimes staff will stand outside the bathroom door, while a patient uses the bathroom and will knock after a "long time". The Security Officer defined a "long time", as "about 5 minutes".

On 12/11/19 at 2:13 PM, ED Nurse (Staff #4) was interviewed. She stated the following:
- She's never been in the bathroom with a patient assigned to the BH area to ensure safety and staff will "sometimes stand outside the door" of the bathroom.
- She confirmed that security staff can sometimes be called away from the security office to respond to other events.
- Nurses do not go into the security office to monitor the patients, but ED staff may monitor psychiatric patients from the nurse's station.
- There is a monitor behind the nurse station that the Unit Secretary may monitor the Behavioral Health area from. Surveyors observed the monitor behind the nurse station and out of live view of the Behavioral Health area.

On 12/11/19 at 2:20 PM, ED Nurse (Staff #5) stated she had never been in the bathroom with a patient to monitor for safety; an ED Technician could be delegated to chaperone a patient; and that she did not recall an instances when she had delegated an ED Tech to accompany a patient into bathroom for safety.

Based on the above observation, record review, and interviews, it was determined that the hospital was aware of the ligature risks in the bathroom utilized by individuals assessed at risk for self harm and did not have an effective policy or system in place to ensure the safety of patients in this bathroom.

IJ represents a situation in which a facility's non-compliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. Based on the above observation, record review, and interviews, it was determined that the hospital was aware of the ligature risks in the bathroom and did not have an effective policy or system in place to ensure the safety of patients in this bathroom. This failure constituted a determination of IJ.

On 12/11/19 at 4:02 PM, the IJ template was provided to the Vice President of Quality and a removal plan was requested.

On 12/11/19 at 6:58 PM, an acceptable removal plan was provided to surveyors.

The acceptable removal plan indicated the following:

- Patients presenting to the ED with any substance use complaint, mental health complaint, or who expresses ideation for self-harm at the time of presentation will be escorted to triage upon arrival.

- Patients would be assessed by the Columbia Suicide Severity Rating Scale.
a. Patients assessed at low risk would be be observed every fifteen minutes until seen by the provider and the low risk status was confirmed
b. Patients assessed at medium or high risk level would be observed (human eyes on the patient) to ensure ongoing safety. Patients would be located in the ED common area, patient rooms, or patient care area.

- The following steps will be taken:
a. Visualization (human eyes on the patient) in the same room would take place by a single staff member with every 15 minute documentation of this observation on the Continuous Observation Log.
b. Every 60 minutes the Charge Nurse would document on the Continuous Observation Log that Continuous Observation (human eyes on the patient) occurred.
c. Should the patient need to use the bathroom, a staff member of the same gender would continue direct visualization (human eyes on the patient) of the patient while in the bathroom with the patient.

- Staff would be be educated about the interim plan by Nursing Leadership to the ED Charge nurse. Confirmation of the education would be documented by staff signature on the Staff Education Verification Sign-Off Sheet.

- The Charge Nurse would be responsible for educating current and oncoming ED staff and providers, as well as the Security staff prior to assuming assignment.

- Each House Supervisor would be advised of the interim plan and would sign the Staff Education Verification Sign-Off Sheet before assuming assignment.

On 12/12/19 at 6:30 AM, surveyors verified that the facility's plan to remove the IJ was implemented and was effective. The surveyors determined the abatement of the IJ by the following:
- Observing the removal plan in several areas within the ED
- ED Charge Nurse (Staff #6) showed surveyors the removal plan. He stated that prior to the IJ removal plan he had not been accompanying patients into the bathroom nor had he assigned other staff to do so and he indicated that Patient #21 had been accompanied to the bathroom for a shower
- Patient #21 stated that he/she had not been accompanied into the bathroom until the evening of 12/11/19.