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Based on observation, document review, and staff interviews, it was determined the facility failed to ensure that the patient's right to receive care in a safe setting and the patient's right to have their pain assessed and managed, is protected.

Findings include:

1) The facility failed to ensure that the patient's right to have their pain assessed and managed, is maintained. (Refer to Tag Q0129)

2) The facility failed to ensure that patients on 1:1 (one-to-one) observation for suicide risk are not left unsupervised while toileting, in accordance with facility policy. (Refer to Tag Q0144)

Based on review of seven of 10 medical records (#2, #3, #5, #6, #8, #9, #10), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that the patient's right to have their pain assessed and managed, is maintained.

Findings include:

Reference #1: Facility policy titled, "Pain Assessment/Management" dated 01/10/23 states, " ... Procedure: 1. Emergency Department (ED) Pain Assessment ... c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record ... 2. Inpatient Admission Pain Assessment ... a. All patients are assessed for pain upon initial assessment ... 3. Inpatient Head-to-Toe, Ongoing and Shift Assessment ... a. Pain will be routinely assessed, reassessed, and documented at regular intervals for: i. A minimum of every shift ... ii. Postoperatively day one ... iii. When transferred from unit to unit ... 4. Reassessment of Pain a. After the administration of pharmacological and/or non pharmacological interventions, a reassessment is completed within 60 minutes."

Reference #2: Facility policy titled, Patient Rights and Responsibilities dated 04/19/22 states, "... Procedure ... The patient has the right to a concerned team committed to pain relief and prevention and to expect and receive appropriate assessment, management and treatment of pain an an integral component of that person's care, in accordance with N.J.A.C. 8:43 E-6."

Review of the medical records of Patients #2, #3, #5, #6, #8, #9, and #10 on 01/19/23 at 11:50 AM, in the presence of Staff #6 (Nurse Educator), Staff #8 (Nurse Educator), and Staff #7 (Nurse Manager), revealed the following:

Patient #2 (P2) arrived in the ED on 01/16/23 at 7:38 PM with a complaint of "Psych [psychiatric] Eval [evaluation]." The initial assessment was documented at 8:11 PM. There was no evidence that an initial pain assessment was performed. Staff #8 (Nurse Educator) confirmed at 12:11 PM that a pain assessment is required during the initial assessment.

Patient #3 (P3) arrived in the ED on 01/18/23 at 8:37 AM with a complaint of syncope. The initial nursing assessment was documented at 9:00 AM. There was no evidence that the patient received an initial pain assessment or any subsequent pain assessments while he/she was in the ED from 9:00 AM to 1:46 PM, when the patient left the ED. Staff #6, Staff #7, and Staff #8 confirmed there was no evidence the patient received pain assessments from 9:00 AM to 1:46 PM.

Patient #5 (P5) arrived in the ED on 12/05/22 at 2:55 PM with an arrival complaint of "injury to head." The initial nursing assessment was documented at 3:07 PM. There was no evidence of an initial pain assessment conducted during the initial nursing assessment.

At 5:00 PM, P5's pain was assessed with a score of "7-severe pain." There was no evidence that pharmacological or non-pharmacological interventions were performed. There was no evidence that P5's pain was reassessed after 5:00 PM. The patient was discharged at 9:41 PM. Staff #6, Staff #7, and Staff #8 confirmed that there was no evidence of interventions or pain re-assessments for P5.

Patient #6 (P6) arrived in the ED on 12/06/22 at 5:09 PM with a complaint of "Pain right side of ear/neck." At 6:00 PM, P6's pain was assessed with a pain score of "5- moderate pain (neck pain)." There was no evidence that pharmacological or non-pharmacological interventions were performed. At 2:16 AM on 12/07/22, 975 mg (milligrams) of Tylenol was given to the patient and the patient was discharged at 2:31 AM. There was no evidence that P6's pain was re-assessed after the Tylenol was given. Staff #6, Staff #7, and Staff #8 confirmed that there was no evidence of interventions or a pain re-assessment for P6.

Patient #8 (P8) arrived in the ED on 01/17/23 at 3:29 AM with a complaint of "Flank Pain." The patient was admitted for a surgical procedure, "Cystopic insertion of stent ureter double-j" and was transferred to unit 7C at 10:31 AM. An initial nursing assessment was documented at 11:08 AM. There was no evidence the patient received a pain assessment with the initial nursing assessment, and when transferred between units, as required by facility policy. There was no evidence that the patient's pain was re-assessed until 8:11 PM, nine hours and 41 minutes after the patient was transferred to unit 7C. Staff #6, Staff #7, and Staff #8 confirmed there was no evidence of an initial pain assessment and that the patient's pain was assessed nine hours and 41 minutes after he/she was transferred to another unit.

Patient #9 (P9) arrived in the ED on 01/15/23 at 10:55 AM and was admitted to unit 7C on 01/15/23 at 2:54 PM. Review of P9's medical record revealed that on 01/16/23, no pain assessment was documented from 7:00 AM to 8:00 PM. Staff #6, Staff #7, and Staff #8 confirmed there was no evidence the patient received a pain assessment from 7:00 AM to 8:00 PM.

Patient #10 (P10) was a same day surgery patient admitted on 01/17/23 to unit 7C. At 5:33 PM, P10 had a documented pain score of "9-Severe Pain." Gabapentin 300 mg (milligrams) was administered for pain. P10's pain was not re-assessed until 8:39 PM, three hours and six minutes after the patient received medication for pain. Staff #6, Staff #7, and Staff #8 confirmed that the patient received a pain re-assessment three hours and six minutes after he/she received medication for pain.

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure that patients on 1:1 (one-to-one) observation for suicide risk are not left unsupervised while toileting, in accordance with facility policy.

Findings include:

Reference: Facility Policy titled, "Care of the Patient Assessed to be at Risk for Suicide" dated 12/18/2020, states, " ... Procedure ... 3. Any patient assessed as at risk for suicide will be placed under appropriate level of interventions ... and implement specific actions accordingly (See Appendix B- Nursing Safety Interventions) ... Appendix B Nursing Safety Interventions ... Moderate Risk ... Order 1:1 sitter and maintain direct visual eye contact at all times at arm's length distance from the patient ... including while patient is toileting ... 12. The 1:1 sitter cannot leave the patient until he/she is relieved or 1:1 sitter is discontinued ... In addition, closed doors or curtains are not permitted; patient may not be left unsupervised even while toileting ... ."

During a tour of the Emergency Department (ED) on 01/18/23, the following was observed:

At 10:55 AM, Staff #4 (Sitter/Spotter) was observed sitting outside of Room #25. Upon interview, Staff #4 stated he/she was performing 1:1 observation for a patient (Patient #2). When asked where the patient was, Staff #4 stated that Patient #2 (P2) was in the bathroom located directly across from where he/she was seated. The bathroom door was closed, with no visualization of the patient possible. The patient exited the bathroom about 30 seconds later during the interview with Staff #4, who indicated the patient was on 1:1 observation for suicide risk.

Review of the P2's medical record 01/19/23 at 11:50 AM, indicated that P2 arrived to the ED on 01/16/23 at 7:38 PM with a chief complaint of depression. The ED timeline states " ... pt [patient] has hx [history] of depression hasn't taken meds since November denies SI [suicidal ideation] and HI [homicidal ideation] brought in because aunt does not believe [he/she] is stable as per patient." A Columbia Suicide Severity Rating Scale was conducted on 01/16/23 at 8:14 PM and the patient was assessed a score of Moderate Risk. One-to-one observation was ordered for the patient on 01/16/23. There was no evidence that 1:1 observation for the patient was discontinued on or before 01/18/23.

During an observation of the patient bathroom on 01/18/23 at 1:20 PM, two bolted grab bars were located next to the patient toilet. One grab bar was positioned horizontally and above it, another grab bar was positioned vertically. There was spacing observed between the grab bars and the wall that was confirmed on 01/19/23 at 3:50 PM with Staff #3 (Risk Manager).

On 01/18/23, a review of the "Environmental Risks for Suicide Assessment Checklist" dated 09/27/22, was performed. The "Environmental Risks for Suicide Assessment Checklist" states, "Are grab bars and towel bars in patient bathrooms removed or designed to resist ligature attachment?" ... "No." ... "Risk mitigation 1:1 sitter will be provided."

On 01/18/23, an Immediate Jeopardy (IJ) was identified for the facility's failure to ensure that a patient at risk for self-harm and on one-to-one observation was not left unsupervised while toileting in a bathroom with identified ligature risks.

The IJ was identified on 01/18/23 at 10:05 AM and the IJ template was submitted to the facility on 01/18/23 at 4:05 PM. An acceptable IJ removal plan was received on 01/19/23 at 2:45 PM. The removal plan was verified 01/19/23 at 3:30 PM. Verification of implementation of the IJ removal plan included the following: review of staff re-education and sign in sheets for all clinical staff that perform (one-to-one) 1:1 observation for patients, and observation and interviews of staff performing 1:1 observation confirming re-education was conducted. The IJ was lifted on 01/19/23 at 4:00 PM.