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Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that 3 of ligature free enviroment for 3 of the 4 behavioral health units and that staff conducted the safety rounds as required. 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 3 of 4 behavioral health units were free from ligature risks. See deficiency cited at A0144-A.

2. The Hospital failed to ensure that the required safety monitoring was completed for 15 of 15 patients on a behavioral health unit. See deficiency cited at A0144-B.

The immediate jeopardy (IJ) was identified at 42 CFR 482.13, Patient Rights, on 7/12/2023, due to the Hospital's failure to ensure that the patient rooms on 3 of 4 behavioral health units were free from ligature risks and that the required safety monitoring for 15 of 15 (Pt.#2 -#5, and Pt. #11-21) patients on the Geriatric Treatment Unit (GTU) were completed, as required. This failure is likely to cause serious harm, injury or death to any suicidal patient receiving care in the behavioral health units.

The IJ was announced on 07/13/2023 at 3:00 PM, during a meeting with the Chief Nursing Officer, Regional Director of Behavioral Health, Nurse Manager of Behavioral Health, Director of Behavioral Health, President/Chief Executive Officer, Patient Safety Specialist, Regional Director of Accreditation, and Executive Director of Hospital Services. The IJ was not removed by the exit date of 07/13/2023.

A. Based on observation, document review, and interview it was determined that, the Hospital failed to ensure that the patient rooms on 3 of 4 behavioral health units were free from ligature risks. This failure is likely to cause serious harm, injury or death to any suicidal patient receiving care in the behavioral health units.

Findings include:

1. A tour of the Geriatric Treatment Unit (GTU) was conducted on 7/12/2023 between 9:45 AM-10:30 AM. There were eight (8) double occupancy rooms (#5101-5116), with fifteen (15) patients on the census. The GTU census sheet indicated that, ten of the fifteen patients were on suicide precautions.There were no patients on 1:1 observation (constant observation of patient, within arms reach of patient). The following ligature risks were identified on GTU:
- Five (501, 5105-6, 5107-08 & 5111-12 and 5115-16) of eight (8) patient rooms had moveable chairs with open arms, and raisable over-the-bed tables with a flat surface that could be used for hanging.
-In patient room #5111-12 on top of the over the bed table, there was a c-pap machine (continuous positive airway pressure-used to treat sleep apnea) with an electric cord, and a hose attached to the machine that were approximately 5 feet long.
-In room #5115-16, a patient (Pt.#2) was observed in bed and appeared to be asleep, there was an oxygen flow meter extending from the wall between the two hospital beds that could be used as a ligature point.

2. On 7/12/2023 at 11:32 AM -12:00 PM, additional observational tours of the ITU (intensive treatment unit) AAU (Acute Adult Unit), and CCU (Comprehensive Care Unit) were conducted. The following ligature points were identified on the following units:

-In AAU (rooms #4125-4138) room #4133 Pt. #22 was in his assigned room (#4133) with the door closed, there was a wheelchair with open arms which can be used as an anchor point for hanging.
-In ITU and AAU, the patients were allowed to be in the rooms with room entrance doors closed.
The entrance doors extend to the top and are flush with the door frame, which could be used as an anchor point for hanging.

Durimg the tour at approximately 12:00 PM, an interview was conducted with E #4 (RN Unit Manager). E #4 stated that Pt. #22 was on suicide precautions. E #4 also stated that it is permitted for patient's to close their door for patient privacy, even if there on suicide precautions.

The census sheets dated 7/12/2023 for the ITU indicated that there were 17 patients on suicide precautions, and in AAU 7 there were 11 patients on suicide precautions at the time of the tour. The physcian's order for the 28 patients were reviewed and indicated that these patients were on suicide precautions.

3. The most recent Hospital Risk Assessment, (3/3/2022), was reviewed. The assessment indicated that, the Identified Medical Equipment (moveable or permanent), chairs, and loose furniture as a medium risk. The plan included, "When medical equipment is necessary staff is present to mitigate risk. 1:1 monitoring for high-risk patients, 15-minute rounds on all other patients ... Carts/trays ... staff conduct 15-minute rounds ... It is recommended to move the chairs out of the room."

4. On 7/12/2023 the clinical record of Pt.#2 (room 5115-16) was reviewed. Pt.#2 was admitted to the Hospital's Geriatric Treatment Unit on 7/10/2023, with a diagnosis of major depressive disorder. The clinical record included the following:
-Behavioral Health Report (entered by MD #1) dated 7/11/2023 a 6:39 PM, "Chief Complaint ... (Pt.#2) came to unit with worsening mood and behaviors, has been suicidal and took overdose of pills and wanted to end his life, very depressed and sad, moody and labile, has unpredictable behaviors and not forthcoming."
-Physician Orders dated 7/11/2023, "Suicide Precautions, Observation, 15 minute checks
7/11/2023 1:39 PM, "oxygen therapy routine protocol... Suicide Precautions... Observation, 15-minute checks." The clinical record did not indicate that a 1:1 or higher level of observations was implemented when oxygen was in use.

5. On 7/12/2023 the clinical record of Pt.#3 (room 5111-12) was reviewed. Pt.#3 was admitted to the GTU on 7/7/2023, with a diagnosis of major depressive disorder. The clinical record included, the following:
-Behavioral Health Report dated 7/8/2023 at 3:50 PM, "(Pt.#3)... presents to the unit with worsening mood, increased depression, and hopelessness... Initially admitted (name of outside hospital) for suicide attempt with 180 capsules... Reason for admission... clinically dangerous instability of the patient. Inability to provide for personal safety..."
-Physician Order dated 7/7/2023 at 9:26 PM, "OK for patient to use home C-Pap machine with current settings."
-Physician Order dated 7/12/2023 at 9:30 AM, "Observation, 15-minute checks... Suicide Precautions. The clinical record did not indicate that a 1:1 or higher level of observations was implemented while the C-pap was in use.

6. On 7/13/2023 the clinical record of Pt.#6 (room 4138 on AAU) was reviewed. Pt.#6 was admitted on 7/10/2023 to the Adult Acute Unit with a diagnosis of bipolar disorder. The clinical record included, the following:
-Behavioral Health Report dated 7/10/2023, "(Pt. #6)... gives minimal reason for attacking the roommate other than she had insulted her in a minor way... per staff... (Pt.#6) having manic episodes at times and can get in altercation... Reason for admission.... Aggressive or homicidal behaviors or attempts... clinically dangerous instability of the patient... Inability to provide for personal safety..."
-Physicians' Order dated, 7/10/2023, "Observation, 15-minute checks... Suicide Precautions... RT (respiratory therapy) C-Pap, continuous order, at night as needed." The clinical record did not indicate that Pt. #6 required a 1:1 or higher level of observation to be implemented while the C-pap was in use.

The Hosipital did not follow the Hopsital's Risk Assessment mitigation strategies for high risk patient that require medical equipment.

7. On 7/12/2023 at approximately 10:15 AM, during the tour an interview was conducted with the Unit Manager E#4. E#4 stated the patient rooms on GTU are set up in the same manner (chair(s) and over-bed-table) and that patients can use c-pap machines or oxygen if needed. The RN (registered nurse) will contact the physician and obtain an order for the c-pap machine or oxygen use, the respiratory therapist will come and set up the machine as needed.

8. On 7/12/2023 at approximately 12:50 PM, an interview was conducted with a Psychiatrist (MD #1). MD #1 was asked if when a patient on suicide precautions requires a c-pap machine or oxygen, are special precautions or increased level of observation implemented for patients. MD #1 responded that he was not aware that patients who required c-pap were allowed on the behavioral health units.

9. On 07/13/2023 at 9:00 AM, an interview was conducted with a Registered Nurse (GTU-RN/E#7). E#7 stated that when a patient requires the use of a c-pap or oxygen while on the unit, the RN calls the physician for an order. The c-pap is provided by the hospital, and a respiratory therapist (RT) comes daily at hours of sleep to set up the c-pap. When the c-pap is not in use the machine should be locked away with the patient's belongings. If the patient is low to moderate risk for suicide, then staff conducts safety rounds every 15-minutes. If the patient is a moderate to high risk for suicide, a 1:1 observation is not initiated, we try to place the patient closer to the milieu (patients' social enviroment) where the nurses can sit closer to that patient.


B. Based on document review, observation, and interview, it was determined that the Hospital failed to ensure the required safety monitoring (15-minute monitoring) for 15 of 15 (Pt.#2 -#5, and Pt. #11-21) patients on the Geriatric Treatment Unit (GTU) was completed.

Findings include:

1. The Hospital's policy titled "Patient Safety Rounds/Environment of Care Safety Rounds" (revised 2/1/22) was reviewed and required, "2. All patients are placed on admitting precautions and monitored every 15 minutes until admitting orders have been processed ... 4. The caregiver assigned to rounds: a. locates each patient, observes ... documents location and behavior on the rounds form every 15 minutes."

2. A tour of the Geriatric Treatment Unit (GTU) was conducted on 7/12/2023 between 9:45 AM-10:30 AM. The 15 patients (Pt.#2-#5 ad Pt.#11-#21) on census had physicians' orders for every 15-minute checks, including 10 patients who were on suicide precautions. During the tour the physician's order for safety precautions for 15 patients were reviewed. No patients were on 1:1 observation (constant observation of patient, within arms reach of patient).

3. The rounding documentation for 7/12/2023 were reviewed and indicated that from 9:00 AM to 10:15 AM, patient rounds were not conducted every 15-minutes as required.

4. On 7/12/2023 at approximately 10:15 AM, an interview was conducted with the unit manager (E#4). E #4 confirmed that the Patient Safety Rounds were not documented on the WOW (workstation on wheels-system used to document patient care) and did not know why they were not conducted. E#4 stated that every 15-minute patient safety rounds should always be conducted by the assigned staff to ensure the safety of all patients.

5. On 7/12/2023 at approximately 10:30 AM, an interview was conducted with the Patient Care Technician (PCT/E#5) assigned to complete the patient safety rounds. E#5 stated that rounding should be completed every 15-minutes, E#5 stated she completed the rounds on the WOW [computer on wheels], but the documentation was not saved for unknown reason.

6. On 7/12/2023 at approximately 11:50 AM, an interview was conducted with a Registered Nurse (RN/GTU-E#8) E#8 stated that staff are assigned at the beginning of each shift to conduct the patient safety rounds. E#8 stated that E#8 was made aware that the rounding was not documented for 7/12/2023 between 9:00 AM to 10:15 AM. E#8 opened the documentation on the WOW for the patient safety rounding for 7/12/2023 between 9:00 AM to 11:15 AM, to show that it had been completed. E#8 stated that the rounding was completed but not saved by the PCT (E#5). The documentation indicated Pt. #2 was located in the community room attending Expressive Therapy, however during this time Pt.#2 was observed to be in his room lying in bed facing the wall.