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Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights by ensuring care in a safe setting. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to to ensure safety precautions and monitoring were in place for psychiatric patients boarding in the emergency department, including an unattended minor (under the age of 18). (A-144 A)

2. The Hospital failed to implement precautions to monitor suicidal patients, in order to prevent elopement and/or harm in the presence of ligature risks. (A-144 B)

An Immediate Jeopardy (IJ) began on 5/7/2023, due to the Hospital's failure to monitor a minor patient (under the age of 18) boarding in the emergency department (ED) as well as suicidal patients in the presence of ligature risks, in order to prevent assault, self-harm, injury, or elopement. Subsequently, an allegation of sexual abuse occured involving the minor patient on 5/7/2023. The IJ was identified at 42 CFR 482.13, Patient Rights and was announced on 7/12/2023 at 3:30 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer/Chief Operations Officer, Director of Nursing (Emergency Services), Director of Quality, Director of Risk Management, ED Manager, Vice President (VP) of Mission Integration, VP of Administrative Services, System VP of Quality and Risk, and a Healthcare Consultant. The IJ was not removed by the survey exit date of 7/12/2023.

A. Based on document review and interview, it was determined that for 2 of 2 (Pt #1 and Pt #2) psychiatric patients boarding in the emergency department (ED), including an unattended minor (Pt #1) and a patient (Pt #2) at risk for suicide and elopement, the Hospital failed to ensure safety precautions and monitoring were in place. Subsequently, an incident of sexual abuse involving Pt #1 and Pt #2 occurred.

Findings include:

1. The Hospital's policy titled, "Safety: Pediatric Patients Protocol" (dated 2/2023), was reviewed and required, "To provide a safe environment for pediatric patients. Children are not to be left unattended ...Parent(s) of Pediatric patients being evaluated for Psychiatric issues are not to leave the patient at any time."

2. Email communication from the Director of Patient Care Services (E#5) to the House Supervisors (dated 5/15/2023), included, "If there is a Pediatric patient in the ED who's guardian has not stayed with them for any reason (per policy they are supposed to remain with their child throughout their stay, including for a BH (behavioral health) assessment, please work with the ED team to ensure the patient is provided a sitter as the minor child is now our responsibility ..."

3. The Hospital's policy titled, "Emergency Department Sitter Guidelines" (dated 2/2023), was reviewed and required, "Emergency Department Sitters are caregivers who provide patients in need of supervision with companionship and appropriate care ...Patients who meet the following criteria may be eligible for a Sitter in the Emergency Department: Suicide ideation. Petitioned and/or certified patients ...C. Patients will remain in a purple hospital gown except for patients in the Acute Rehab Unit ...Emergency Department Sitters will: 1. Maintain continuous visual monitoring of the patient at all times, i.e., bathing, test, eating, toileting, etc. ..."

4. The clinical record for Pt #1 was reviewed on 7/10/2023. Pt #1 presented to the ED, via ambulance, on 5/5/2023, for a psychiatric evaluation, chief complaint was behavior concerns. Pt #1 was discharged home on 5/8/2023. Pt #1's record included:

- Pt #1's Triage Nursing Note, documented by the ED Registered Nurse (E #2), dated 5/5/2023 at 8:01 PM, included, "Arrived via [local EMS] accompanied by police escort s/p [status post] altercation with her adoptive mother ...Awaiting arrival of mother for permission to treat."

- A subsequent note by E #2, dated 5/5/2023 at 8:39 PM, included, "[Pt #1's] mother still not present at bedside. Called and spoke with [mother] whom gave verbal consent over the phone. She was informed that an adult must be present at all times due to [patient] being a minor. She stated that she had to pick up a child from work and she will be here 'when I can'."

-Pt #1's Behavioral Health Note, documented by the Crisis Worker (E #4), dated 5/5/2023, included, "Pt is 14 y/o young lady arrives with her sister [minor] for a psych assessment following a physical altercation at home and pt presents at ED saying she doesn't feel safe at home ...The mother has not arrived until now and is not answering her home [phone]. When the charge nurse took the radio call the mother was saying she will not come to the ED and wants the pt hospitalized ..."

- The ED Nursing Notes from 5/5/2023-5/8/2023, were reviewed and included the following on:
5/6/2023 at 2:30 AM: "Mother still has not arrived."
5/6/2023 at 4:25 AM: "Patient transferred from OFHW21 (hallway cart) to OFHWPRO (another hallway cart)."
5/6/2023 at 4:01 PM: "Patient transferred from OFHWPRO (hallway cart) to OFHW26 (hallway cart)."
5/6/2023 at 6:09 PM: "Patient resting on ED cart, calm and cooperative at this time. Bathroom privileges offered."
5/7/2023 at 1:49 PM: "Asked pt to stop talking to other patients."
5/7/2023 at 3:32 PM: "Pt told by sitter to stop talking to the gentleman in the hallway."

- Pt #1's ED Provider Note, documented by the ED Physician (MD #2), dated 5/8/2023, included, " ...5:35 PM, Was informed by nursing staff that the patient [Pt #2] and a female minor patient [Pt #1] was locked in the bathroom together. States that they had security open the door and found them together in a bathroom. They were separated and [local police] department was notified. Security went to the footage and states that per video footage around 5:00 PM [on 5/7/2023] the female patient [Pt #1] were making gestures to each other [with Pt #2]. States that at 5:18 PM they continue to make gestures to go to the washroom together. At 5:19 PM the female enters the washroom herself followed by the patient [Pt #2] when they locked the door. ED nursing staff walked by and noticed immediately that both were missing from the bed and called security to open the door ...Patient [Pt #1] told nursing staff that they were kissing on the lips, he [Pt #2] touched her breast, and touched her bottom. Patient denies any penetrating physical contact."

- Pt #1's Physician orders, dated 5/5/2023-5/8/2023, were reviewed. There were no orders for monitoring, precautions, sitter, or a 24-hour companion.

5. The Hospital's video surveillance from the ED hallway (on 5/7/2023) was reviewed. The video footage included the following on 5/7/2023:
- 17:19:11 (5:19 PM): Pt #1 got off the ED hallway cart.
- 17:19:49: Pt #1 entered the ED hallway bathroom unattended.
- 17:20:49: Pt #2 gets off the ED hallway cart and follows behind Pt #1 into the hallway bathroom.
- 17:20:54: ED RN (E #3), looked towards both Pt #1 and Pt #2's unoccupied carts. Turns towards nursing station as she appeared to have a conversation with the staff sitting there.
- 17:21:06: E #3 walks towards the hallway bathroom and knocks on the bathroom door.
- 17:21:28: The Security Officer (E #10) approaches the bathroom door and then Pt #2 exits.
- 17:21:39: Pt #1 then exits the bathroom and returns to hallway cart.
- 17:57:01: (36 minutes after exiting the bathroom): Pt #1 transferred to Room 09 (room not equipped with video monitoring). Pt #1 closed the privacy curtain that covered that door window after she was placed in the room. There was no staff designated or assigned to sit with Pt #1 when she was placed in Room 09.
- 18:08:43: Local police arrived and entered Pt #1's room with the ED Manager (E #1).

6. The clinical record of Pt #2 indicated that Pt. #2 was a 39-year-old male who presented to the ED via ambulance on 5/6/2023 with suicidal ideation. Pt. #2 was deemed a high suicide risk and had an emergency detention order in place (indicating that he was unable to leave the ED without clearance from the physician). Pt #2 was able to abscond (unknowingly left) from the ED on 5/6/2023, and then on 5/7/2023 was able to enter and use a common ED bathroom that contained various ligature risks (see A-144 B.) and while Pt #1 was in the bathroom, all while unattended. Pt #2's record lacked any orders for monitoring, including suicide and elopement precautions.

7. On 7/10/2023 at 4:30 PM, an interview was conducted with the ED RN (E #3/assigned to Pt #1 and Pt #2) on 5/7/2023 at time of incident. E #3 stated that she was passing meds, and as she was walking down the hall, she noticed both Pt #1 and Pt #2 were not on their carts in the hallway. E #3 stated that she turned to the staff sitting behind the video monitor at the nurses' station, to ask where those patients were. E #3 stated that a 3rd patient that was on the cart in the hallway responded and stated that they were in the bathroom together. E #3 stated that at that point she went to the bathroom to get them out and asked for security to assist. E #3 stated that prior to the incident, she had to keep telling Pt #1 to stop talking to the other patients in the hallway. E #3 stated that in hindsight now, she could have separated Pt #1 sooner. E #3 stated that if a parent is not with a minor, then a staff member should be with them.

8. On 7/11/2023 at 9:05 AM, a telephone interview was conducted with the ED Attending Physician (MD #1). MD #1 stated that with a minor patient, there should always be a parent or guardian with them. MD #1 stated that if there is not an adult present, then there should be a sitter with the patient.

9. On 7/11/2023 at 9:20 AM, an interview was conducted with the ED RN (E #2). E #2 stated that with a minor patient, a parent should be always present with them to keep an eye on them. E #2 stated that if the parent is not there, then the patient should be kept close. E #2 stated that Pt #1 did not specifically have a staff member assigned to her, but E #2 always kept Pt #1 in her sight.




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B. Based on document review, observation, and interview, it was determined that for 3 of 3 patients (Pts. #2-#4) presenting to the emergency department (ED) with suicidal ideation, the Hospital failed to ensure care in a safe setting by implementing precautions to monitor suicidal patients, in order to prevent elopement and/or harm in the presence of ligature risks. This has the potential to affect the health and safety of any current or future suicidal patients in the ED.

Findings include:

1. The Hospital's policy titled, "Suicide Risk Assessment Procedure" (dated 10/2022), was reviewed and required, "Initial assessment: Nursing to complete the Columbia Suicide Severity Rating Scale [C-CSSRS/suicide screening tool] short version upon first point of entry (admission or arrival) for all inpatients, behavioral health patients, ED patients ...After completing the C-SSRS short version: c. If patient answers 'Yes' to question 4,5, and/or 6, indicating it was within the last 3 months: High Risk. Immediately: Notify attending physician to alert of patient with high suicide risk. Order and start Suicide Precautions. Request a Psychiatry/Behavioral consult ..."

2. The Hospital's Procedure titled, "Suicide Precautions Procedure" (dated 12/2022), was reviewed and required, "...In emergent situations suicide precautions may be intiated by a registered nurse (RN)... Notify the attending physician and obtain a physician's order as soon as possible... Constant observation surveillance (patient companion) requires: 1. Continuous visual observation or one to one observation in which a staff member is assigned to observe only one patient at allt imes... 3. Escort and observe patient while patient is using the bathroom..."

3. The Hospital's policy titled, "Emergency Department Sitter Guidelines" (dated 2/2023), was reviewed and required, "Emergency Department Sitters are caregivers who provide patients in need of supervision with companionship and appropriate care ...Patients who meet the following criteria may be eligible for a Sitter in the Emergency Department: Suicide ideation. Petitioned and/or certified patients ...C. Patients will remain in a purple hospital gown except for patients in the Acute Rehab Unit ...Emergency Department Sitters will: 1. Maintain continuous visual monitoring of the patient at all times, i.e., bathing, test, eating, toileting, etc. ..."

4. The Hospital's policy titled, "Patient Elopement Guideline" (dated 7/2022), was reviewed and required, "...All Emergency Department (ED) patients being considered for or who are certified for involuntary admission to a psychiatric facility will be kept under direct visual supervision at all times..."

5. The clinical record for Pt. #2 was reviewed on 7/10/2023. Pt. #2 presented to the ED via ambulance on 5/6/2023 with a chief complaint of S.I. (suicidal ideation). The Columbia Suicide Severity (suicide screening tool), dated 5/6/2023 at 8:36 PM, indicated that at the time of triage, Pt. #2's suicide risk level was deemed as high risk. The Petition for Involuntary Admission, dated 5/7/2023, indicated that patient was in need of immediate hospitalization for the prevention of harm. The HPI (history of present illness), dated 5/6/2023, included, "Patient did initially try to abscond [unknowingly left] but was found outside smoking a cigarette ...Patient was escorted back in ..." An ED Provider Note (dated 5/7/2023), included, "Patient was evaluated ...Patient stated that he wanted to slit his wrist and was going to kill himself. Patient will be an EDO [emergency detention order]." Pt. #2's physician orders were reviewed and did not include any orders for any monitoring, including suicide or elopement precautions."

6. The clinical record of Pt. #3 was reviewed on 7/10/2023 and indicated that Pt. #3 presented to the ED on 7/10/2023 at approximately 2:25 PM and was put into Room #14, which was not a designated behavioral health room with video monitoring capabilities. Pt. #3 presented with chief complaints of suicidal and drug overdose and was deemed a high risk for suicide. Physician orders, dated 7/10/2023 at 2:46 AM, included suicide precautions and "sitter at bedside." At approximately 8:09 AM, nursing notes indicated that no sitter was available to monitor the patient for suicide risk, and alternate interventions included having the room close to nursing station, contraband check, and room check. Pt. #3 was documented to have been moved into Room #24 (a behavioral health room) on 7/10/2023, at 9:21 AM. The record lacked documentation that a sitter was ever placed at bedside to monitor Pt. #3.

7. The clinical record of Pt. #4 was reviewed on 7/10/2023 and indicated that Pt. #4 presented to the ED on 7/9/2023 with a chief complaint of suicidal. Physician's orders included suicide precautions and an active order for "sitter at bedside" The record lacked documentation that a sitter was ever placed at bedside to monitor Pt. #4.

8. Video surveillance footage of the ED BH area on 5/7/2023 was reviewed on 7/10/2023 and 7/11/2023. The following was observed: On 5/7/2023, at approximately 5:20 PM, Pt. #2 walked past the nurses station where a video monitor tech was stationed. (The video monitor tech was assigned to watch all 6 BH patients in the rooms via video in addition to the 3 hallway patients present). Pt. #2 entered the common BH ED bathroom and was able to lock the door of the bathroom. Pt. #2 was not under constant visual monitoring while using the bathroom that contained various ligatures risks.

9. A tour of the Emergency Department (ED) was conducted on 7/10/2023, at approximately 11:10 AM. The Main B / Behavioral Health area included 6 behavioral health (BH) rooms (Rooms #21-26) with 4 hallway beds that were located in front of the nurses' station. There were 6 behavioral health patients present, of which 5 were placed in the rooms with video monitoring and one was on a hallway bed in front of the nurses' station. There were two hall monitors and a security guard present in the BH hallway. A Patient Care Attendant/PCA (E#8) was also sitting at the nurses' station monitoring video of the 5 patients in the BH rooms, as well as monitoring the patient on the hallway cart. E#8 had "ED Hourly Safety Logs" for each of the patients, except for Pt. #3. E#8 stated that Pt. #3 may have just been brought into the room, and E#8 did not have any information on him yet. Pt. #3 was in room #24 laying on an ED cart with a bed sheet covering his head and body. There was an IV (intravenous) pole present in the room with a bag of fluids infusing via tubing. Pt. #4 was in the next room (#25) and was laying on a platform (solid) bed, covered entirely by a bed sheet. A call light with a cord was observed on the floor behind the bed. None of the patients had a designated sitter at the bedside, as ordered.

- There were 3 common bathrooms available for use near the BH area. One was designated for behavioral health patients; however, per interview with ED staff including the ED Manager (E#1), Charge Nurse (E#3), Hall Monitor (E#9), and Security Guard (E#11), any of the bathrooms could be used by BH patients if that specific one was occupied and that BH patients are able to use the bathrooms without constant visual monitoring by staff (door closed and locked). The designated BH bathroom contained the following ligature risks: exposed pipes, protruding door hinges & handles, toilet seats with anchor points, a protruding flat-surfaced light fixture, and a plastic garbage bag. The other common bathrooms contained the same ligature risks in addition to non-ligature-resistant fixtures such as faucets, soap dispensers, paper towel dispensers, toilet paper dispensers, grab bars, and 3-feet long call light cords.

10. During a telephone interview with E#8 (Patient Care Attendant/PCA) on 7/11/2023 at approximately 1:07 PM, E#8 stated that she floats to the ED occasionally if they need help. E#8 stated that the nurse usually gives the sitters a brief report on the patients when they arrive. E#8 stated that as the video monitor, she is responsible for visually monitoring all of the patients in the rooms and the ones in the hallway. E#8 states that she watches their behavior and makes sure staff are okay as well. E#8 stated that when monitoring multiple patients, "realistically if I take my eyes off a patient even for a second, I might miss something." E#8 stated that if a patient needs to use the bathroom, and "if I'm a hall monitor at that time, I will escort them to the bathroom and wait outside with the door closed."

11. An interview was conducted with the ED Physician (MD#2) on 7/10/2022 at approximately 2:20 PM. MD#2 stated that when an order is placed for "sitter at the bedside" it means there should be a designated 1:1 staff member sitting with the patient to monitor him/her (and not other patients at the same time).