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Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to ensure that safety precautions and appropriate monitoring were in place for patients at risk for suicide. See deficiency at A-144.

An immediate jeopardy (IJ) began on 02/10/2024, due to the Hospital's failure to monitor behavioral health patients that presented to the emergency department, who were at risk for suicide, in order to prevent self-harm or injury. Subsequently, a patient attempted suicide resulting in physical injury and need of resuscitative measures. The IJ was identified on 02/21/2024, at 42 CFR 482.13, Patient Rights. The IJ was announced on 02/21/2024 at 3:30 PM during a meeting with the Interim Chief Executive Officer, the Quality Risk Specialist, the Director of Emergency Services, and Director of Quality. The IJ was not removed by the survey exit date of 02/21/2024.

Based on document review, video review, observation, and interview, it was determined that for 2 of 2 psychiatric patients (Pts. #1 and #11) in the Emergency Department (ED), the Hospital failed to ensure that care was provided in a safe setting by failing to ensure that safety precautions and monitoring were in place. Subsequently, an incident of attempted suicide occurred involving Pt. #1 on 02/11/2024. 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, "Care Mngmt [Management] Behavioral Health Patient" (revised 10/10/2023), was reviewed and required, "Patients who present to the ED with a history or symptoms of mental illness or emotional disturbance shall be first of all protected from doing harm to themselves and/or others. Self-harm precautions are implemented by the nursing staff for patients who have either harmed themselves, verbalized intent to do so, or indicated, in an overt or covert manner, a wish to do so ... Suicide precautions are initiated in the patient room. Potentially harmful items/equipment are removed ... If the patient scores a Moderate or High Risk on the Suicide Screening Risk Assessment tool and/or has a Petition completed, a sitter/security must be present until the patient is transferred from the hospital ... Emergency Department process for checking belongings: Patient belongings are to be removed from the patient upon arrival. Belongings will be inventoried by 2 staff members ... Personal belongings will be documented using documentation in the electronic medical record ... Observation and/or assessment documentation will occur at least every hour, utilizing the EHR [Electronic Health Record] (Care Rounds) ... Patient will be escorted to and from the designated behavioral health bathroom ..."

2. The clinical record of Pt. #1 was reviewed on 02/15/2024. Pt. #1 presented to the ED on 02/10/2024, at approximately 11:00 PM, for evaluation of hallucinations.

- Triage notes included, "Brother and patient admit that patient has been hearing voices, patient states the TV is talking to him telling to go to the tower. Brother reports patient is able to see the radio antenna from his home. Brother states he is reading the bible upside down, patient states the bible voices are telling him to confess his sins. Patient states he hasn't slept in a couple days ... Patient denies suicidal or homicidal ideations. Patient denies the voices are telling him to harm himself or others ..."

- Pt. #1's Behavioral Health Patient Assessment, dated 02/10/2024 at 11:46 PM, included "Symptoms/Complaint/History: Auditory Hallucinations, Visual Hallucinations, Delusions, Anxiety, Recent Drug Abuse, Not taking psych meds, significant life stressor. Getting Worse ... Suicidal Ideation: None ... In the past two weeks, have you felt down, depressed, or hopeless? Yes ... Interventions: Safe Room and Patient Checklist: ...Suicide Precautions Initiated, All Loose Items Removed from the Room ... Hallucination Type: Auditory, Visual, Command ..."

- A Nurse's Note on 02/11/2024 included, "Patient found by security at 3:08 AM for snoring respirations and discoloration to the head. Security stated this was tied around patient's neck, holding up a pillowcase. This RN entered the room at 3:08 AM, patient observed unconscious to have snoring respirations, cyanotic head, drooling secretions, radial pulse palpated. This RN called for code blue and assistance. Patient was immediately transferred to room 6 [trauma room] ..."

- The record lacked documentation that a staff/sitter was assigned to monitor Pt. #1 while in the ED from the time of arrival until the time of the incident (approximately 3:08 AM).

- The Behavioral Patient Belongings Check was not completed until 02/11/2024 at 6:04 AM, which included: "hoodie, grey tennis shoes, socks, belt ..."

- Pt. #1 was transferred via ambulance to another hospital for higher level of care due to "Strangulation, esophageal perforation, pneumomediastinum ..." on 02/11/2024 at approximately 9:49 AM.

3. The clinical record of Pt. #11 was reviewed on 02/20/2024. Pt. #11 presented to the ED on 02/19/2024 at 3:03 PM, with a behavioral health complaint.

- Pt. #11's triage note, dated 02/19/2024 at 3:34 PM, included, "Arrived per EMS [ambulance] after attempting suicide. Patient is alert, oriented and cry[ing] on arrival. Made several attempts to cut [Pt. #11] 'carotid artery' with a box cutter and also attempted to [hang] from [Pt. #11] bed with a cord to 'speed up the process'."

- The Psychiatric HPI (History of Present Illness), dated 02/19/2024 at 3:40 PM, included, " ... [Pt. #11] with a history of mental illness and previous suicide attempts presents after attempting to cut her neck numerous times with a carpet cutter? box cutter? At 12:30 p.m. this afternoon (approximately 2 hours prior to arrival) Pt. #11] states [Pt. #11] tried to wrap something around [Pt. #11] neck as well but did not have the proper cord to hang [Pt. #11] ...states [Pt. #11] was tired and just wanted to die ..."

- Pt. #11's Behavioral Health Patient Assessment included the initial suicide screening on 02/19/2024 at 3:41 PM, indicating that the patient feels depressed; suicidal ideation; admits thoughts of self-harm with plan. Pt. #11's initial suicide screening score was 4, indicating moderate risk. Subsequent suicide/safety screening scores were scored as high risk (5), on 02/19/2024 at 8:00 PM and then (6) on 02/20/2024 at 8:00 AM.

- Pt. #11's patient's belongings inventory check was done on 02/19/2024 at 4:52 PM (1 hour 49 minutes after arrival) and did not include stockings.

- Pt. #11's clinical record indicated that a sitter/security was put in place starting on 02/19/2024 at 7:00 PM. The Behavioral Care Rounds notes (that documents interventions in place) indicated that there was a time lapse of a sitter/security guard at the bedside (on 02/20/2024 at 5:00 AM-7:09 AM/2 hour and 7-minute gap)

- A Care Rounds Note, dated 02/19/2024 at 11:30 PM (nearly 8 hours after arrival), included, "upon helping patient to bathroom I noticed that she had stockings tied around both of her thighs, given new scrubs, cut off of her legs at this time and pt states, 'I was going to use those to hang myself.'"

- A Behavioral Health Rounds note, dated 02/20/2024 at 7:09 AM, included, "Patient Comfort Provided: Door Closed-Noise Reduced, Lights Dimmed..."

- Pt. #11 was transferred to a behavioral health facility on 02/20/2024 at 10:45 AM.

4. Video surveillance footage of the ED on 02/11/2024 was reviewed and indicated that Pt. #1 was roomed in designated behavioral health room (#12) in the ED upon arrival on 02/10/2024 at approximately 11:11 PM. Pt. #1 was accompanied in the ED by the brother and mother. At approximately 1:43 AM, Pt. #1 was escorted by ED Nurse (E#3) to the bathroom across the hall. Pt. #1 went to the bathroom, while E#3 returned to the nurses' station (with no direct visualization of the bathroom). While Pt. #1 was in the bathroom, E#3 went to another hallway and then back to the nurses' station, never returning to the bathroom where Pt. #1 was. At approximately 1:48 AM, Pt. #1 comes out of the bathroom and walks towards the nurses' station to give the sample cup to E#3. At approximately 1:52 AM, E#3 turned off the light in Pt. #1's room. At approximately 1:54 AM, Pt. #1's family (brother and mother) walked out of the room (leaving Pt. #1 alone in the room) and the family spoke with E#3 before leaving the ED. At approximately 2:06 AM, E#3 walked past Pt. #1's room and looked into Pt. #1's dark room for about a second and then continued down the hall. Between approximately 3:03 AM-3:07 AM, a Security Guard (E#6) was standing at the nurses' station and had looked into Pt. #1's room about 5 times. At approximately 3:08 AM, E#6 walks away from the nurses' station and stops in front of Pt. #1's room and walks to the doorway to look inside. E#6 turns on the light and walks into the room. E#6 comes out and shortly after, E#3 runs into to the room. Multiple staff (including MD#1) are seen coming to or near the room and bringing the crash cart. At approximately 3:09 AM, Pt. #1 is wheeled out of the room and was taken to the trauma bay. Pt. #1 appeared cyanotic (bluish-purple in color) and unresponsive/unconscious. It was noted that Pt. #1's belongings were not removed prior to the incident.

5. During a tour of the ED on 02/15/2024 at 10:30 AM, it was noted that the ED had 2 patient bathrooms. One of the bathrooms, was designated for behavioral health patients. The designated behavioral health bathroom had a call light pull cord (approximately 2 feet long). The bathroom door was designed with a break-away lock that allows staff to enter from the outside if emergency entry is required. The Charge RN (E #4) stated that patients are allowed to use the bathroom with the door closed. E #4 stated that the staff should stay outside of the bathroom, when the behavioral health patient is in the bathroom. E #4 attempted to open the door from the external side while it was locked (for demonstration purposes). E #4 was unable to open the door.

6. On 02/20/2024 at approximately 12:00 PM, an additional tour of the ED was conducted with ED Director (E #2). E #2 attempted to open the patient bathroom from the external side. E #2 was able to enter after 1 minute. E #2 stated that there is a pull cord in the bathroom because there are times when non-behavioral health patients use that bathroom, and they may need to call for assistance.

7. An interview was conducted with ED Charge Nurse (E#4) on 2/15/2024, at approximately 3:00 PM. E#4 stated for suicidal patients, "we monitor them when they are in the hallway and visually watch them from the outside. We don't do direct visualization for privacy reasons." E#4 stated that after this incident they received an email outlining a process change to remove pillows from behavioral patient rooms and switching to fitted sheets instead of flat sheets. E#4 was not aware of any other changes implemented since the incident occurred. E#4 stated that only patients who are in restraints would receive 1:1 monitoring. E#4 stated that the Hospital does not have designated sitters, they use either security, nursing staff, or the secretary.

8. An interview was conducted with the Director of the ED (E#2) on 2/15/2024, at approximately 3:25 PM. E#2 stated they completed a root cause analysis on Monday (day after the incident) and one of the suggestions was to remove the pillow cases and switching to fitted sheets so that it would be more noticeable if the sheet was being removed from the mattress. E#2 stated that they are still trying to seek out other opportunities to identify additional risk factors that may have led to this incident and could not voice any additional measures implemented in response to this incident. E#2 presented a copy of the email that was sent out to ED staff on 2/13/2024 regarding the new linen protocol for behavioral health patients.

9. Interviews with ED Nurses (E#5 and E#3) were conducted on 02/20/2024, at 9:35 AM and 11:30 AM respectively. Both E#3 and E#5 sated that 1:1 monitoring is only done when a patient is restrained or is agitated/aggressive. E#3 stated that psychiatric patients are able to use the bathroom privately with the door closed. E#3 stated that the nurse does not need to stay by the bathroom door as long as they remain in the vicinity. E#5 was not aware that the bathroom door could be locked. Both E#3 and E#5 stated that patient's belongings are not removed unless the patient is being involuntarily petitioned for admission.

10. An interview with the Security Guard (E#6) was conducted on 2/20/2024, at approximately 10:00 AM. E#6 stated that E#6 had come to the ED the night of the incident because another patient had arrived in police custody. E#6 stated E#6 had looked into Pt. #1's room several times due to snoring sounds, but the room was dark and the patient was side lying facing towards the wall (away from the door) and had a blanket/sheet pulled up all the way covering the bottom half of his head and upper body. E#6 stated that some fabric was wrapped tightly around Pt. #1's neck. E#6 stated that after that a security guard was stationed outside of the patient's room. E#6 stated that there is usually only two security guards on duty for the whole hospital at night. E#6 stated that E#6 has had no specific training in regards to monitoring of patients.

11. An interview with the Quality Risk Specialist (E#1) was conducted on 2/20/2024, at approximately 11:45 AM. E#1 stated that besides removing the pillowcases and changing to fitted sheets, no other corrective actions have been taken thus far in response to this incident.