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Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when P1 was found unresponsive in his room. P1 was bleeding from his eyes, nose and mouth, and had a strip of a towel wrapped around his neck. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

A condition level deficiency was issued.

Findings include:

See A-0144; Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when P1 was found unresponsive in his room. P1 was bleeding from his eyes, nose and mouth, and had a strip of a towel wrapped around his neck. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) when P1 was found unresponsive in his room with a strip of a towel used as a ligature wrapped around his neck. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 6/6/23, at approximately 10:02 p.m. when P1 was found unresponsive in his room laying on his mattress. P1 was bleeding from his eyes, nose and mouth, and had a strip of a towel wrapped around his neck. On 6/14/23 at 3:15 p.m., nurse executive (NE)-A, the executive director (ED), the administrator, hospital administration (HA)-A, the director of operations (DO), and director of nursing services (DNS) were notified of the IJ. The IJ was removed on 6/15/23, when an acceptable removal plan was verified as being implemented; however, the hospital remained out of compliance with the COP - Patient's Rights at 42 CFR 483.13.

Findings include:

A report to the State Agency (SA) dated 6/7/23, indicated P1 was placed on his own subunit for his recent history of suicidal ideation, disrobing, spitting on staff, and serious assaults. While in the subunit, staff were monitoring P1 per order every 15 minutes. P1 was observed and did not appear in distress at 9:47 p.m. Staff completed rounds at 10:02 p.m. where they noted P1 in distress. P1 had ripped a towel and tied it around his neck. Staff immediately called for help and removed the towel around P1's neck. P1 initially was not verbally responsive as nursing staff began assessing P1's vital signs. Police and ambulance arrived on scene and left with P1 at 10:26 p.m. to transport to the local emergency room for further evaluation with two facility staff as escort.

P1 was a 23-year-old male admitted to the facility on 5/9/23. P1' s diagnoses included suicidal ideation, schizophrenia, psychosis, and antisocial traits.

P1's admission Physician's Orders included Intensive Care Area (ICA) Low Stimulus Environment (LSE) due to his history of suicidal ideation, disrobing, spitting at staff and serious assaults on staff. The LSE consisted of Staffing Level: Distant 2:1 staff, routine observation (which included 15-minute checks of the patient, and environmental rounds every shift), and approach in pairs when conducting safety rounds.

On 5/24/23 at 1:30 p.m., a progress note indicated P1 had torn a towel and had placed the pieces of the towel around his neck. P1 denied the urge to self-injure, and he had been assessed by the primary psychiatric provider. No new orders were put in place.

On 5/26/23 at 2:54 p.m., a progress note indicated P1's room was checked, and strips of a towel were found. P1 was assessed by the psychiatric provider and was placed on frequent (5-minute) checks. P1's 5-minute checks were discontinued on 5/29/23, and routine observation (15-minute checks) were put back in place.

On 6/6/23, at 11:15 p.m. a progress note indicated P1 was found in his room by staff unresponsive with a piece of torn towel around his neck during routine safety rounds at 9:59 p.m. Human services technician (HST)-A removed the torn towel from around his neck. Medical ICS was activated at 10:01 p.m. P1 did not respond verbally, but nodded his head when staff talked to him. At 10:05 p.m. emergency medical services (EMS) was called and at 10:22 p.m. P1 was brought to ED by EMS for further assessment.

P1's hospital discharge orders dated 6/7/23, included diagnosis of asphyxiation by strangulation, intentional self-harm, epistaxis (bleeding from the nose), abrasion of lip, and conjunctival (hemorrhage of both eyes). Discharge instructions included do not allow the patient to have towels, cords, shoelaces or any objects that he could use to strangle himself going forward. If any point time P1 had persistent vomiting, trouble talking or swallowing, troubles breathing, or if P1 had neck swelling, P1 was to return to the ED immediately.

On 6/13/23 at 12:21 p.m., video review of the Intensive Care Area (ICA) Low Stimulus Environment (LSE) with registered nurse (RN)-C and management analyst (MA)-A indicated the following:
From 6/1/23 to 6/5/23, staff did not complete environmental room checks for P1.
On 6/4/23 at 2:09 a.m., P1 was given clean towels, but did not give staff soiled towels from unidentified direct care staff who were assigned 2:1 with routine checks.
On 6/5/23, at 10:20 a.m. HST-A and HST-B were observed removing a visibly torn towel from P1's room.

On 6/14/23 at 10:25 a.m., HST-B was interviewed and stated she had not been aware she was supposed to be checking P1's room every shift or when completing safety checks. HST-C further stated she had no knowledge of the policy of exchanging soiled linens for clean linens. HST-B further stated it had been herself and HST-A who had found the torn linens in P1's room on 6/5/23; however, she did not report this to the charge nursing staff.

On 6/14/23 at 10:54 a.m., HST-A stated she was not aware she was supposed to be checking P1's room every shift. HST-A also stated she found the torn towel in P1's room, and she could not remember if she reported it or not.

On 6/14/23 at 11:35 a.m., mental health program assistant (MHPA)-A was interviewed. MHPA-A stated he was the staff who found P1 on 6/6/23. MHPA-A stated he was doing 15-minute checks on P1 when he found him unresponsive in his room. MHPA-A stated he thought P1 had a seizure, then noticed P1 had cloth sticking out from around his neck. MHPA-A stated P1 was bleeding from his eyes, his nose and his mouth, and he was also foaming from his mouth. MHPA-A stated the strip of towel was wrapped tightly six times around P1's neck. MHPA-A stated he called for help and removed the towel from P1's neck. MHPA-A stated he was not aware P1's room was to be checked every shift. MHPA-A also stated he was not aware he should be receiving soiled towels when they were providing patients with clean towels.

On 6/14/23 at 11:49 a.m., RN-A was interviewed. RN-A stated staff were supposed to be doing environmental checks as part of routine observation on patients in the LSE. RN-A stated this included checks of the patient's rooms, and was to be done every shift. RN-A also stated staff was supposed to be asking for soiled towels when they give patients clean towels. RN-A stated failure to account for items such as linens and failure to perform environmental checks could put patients at risk for self-harm.

On 6/14/23 at 12:12 p.m., RN-B stated she was not aware staff was not receiving soiled towels when they would give P1 clean towels. RN-B also stated she was not aware staff had removed a torn towel from P1's room. RN-B stated staff should have reported to her and the physician due to this being a ligature risk. RN-B also stated staff were to be checking P1's room every shift as part of the LSE. RN-B stated she was had no knowledge that direct care staff were not completing safety checks per policy which included inspecting the patients' rooms for items such as torn linens. RN-B stated failure to account for items such as linen and perform environmental checks could put patients at risk for self-harm.

On 6/14/23 at 12:12 p.m., the DNS stated P1 had a prior incident of tearing towels and wrapping strips around his neck. The DNS further stated the facility had identified staff had not been completing safety checks per facility policy prior to the incident involving P1 on 6/6/23. The DNS stated staff were expected to account for items such as linen, and were to perform environmental checks. Failure to do so could put residents at risk for self-harm.

P1's psychologist was unavailable for interview.

The facility policy Linen Exchange updated 5/2/23, directed staff is to ensure all items are accounted for by exchanging the same amount of linens as turned in.

The facility policy Routine Rounds and Client Safety Checks policy dated 11/1/22, directed staff are to scan rooms for linen that is torn, frayed, stained, worn or otherwise unsuitable. Staff are to report any safety or cleanliness concerns in the client's room or secured areas to the charge nurse lead worker. Environmental rounds (a thorough inspection of the treatment environment, including areas that are not easily observed during normal day-to-day activity) are to be completed at the beginning of every shift.

The IJ was removed on 6/15/23, at 12:45 p.m. when the hospital had submitted and implemented an acceptable removal plan which included appropriate education and training of all employees, including licensed nurses, mental health program assistants and human services technician. This was verified through observation, interview and policy review.