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Based on observation, interview, record review and policy review, the hospital failed to ensure:
- Four current patients (#19, #35, #36 and #37), of four patients observed, were provided psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) after being placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm);
- Staff followed policies and procedures when one to one (1:1, continuous visual contact with close physical proximity) observations were not implemented and documented for two current high-risk suicidal patients (#19 and #35), of four patients observed; and
- One current patient (#36), of four patients observed, was properly assessed by a provider after being placed on suicide precautions. (A-0144)

These failed practices resulted in a systemic failure and noncompliance with 42
CFR 482.13 Condition of Participation (CoP): Patient's Rights. The hospital census was 450.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 06/04/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on the assessment and observation of patients placed on suicide precautions. All remaining staff were educated prior to the start of their next shift.

Please refer to A-0144.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for one Emergency Department (ED) discharged patient (#41) of one discharged ED patient reviewed and all current ED continuous telemetry monitored patients.
- Ensure the assigned nurse rounded every hour and documented the rounding in the electronic health record (EHR) for four current patients (#19, #35, #36, and #37) out of four current patients observed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm).
- Ensure appropriate nursing assessments were completed and documented on three current patients (#19, #36, and #37) out of four current patients on SP.
- Ensure that physician notification, appropriate consults and orders were obtained, when one patient (#37) had a significant change in a risk for suicide out of four current patients on SP observed.
- Ensure that nursing documentation for one to one (1:1, continuous visual contact with close physical proximity) observations were completed on two current suicidal patients (#19 and #35) out of four current patients on SP observed. (A-0395)

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 06/05/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on the expectation that designated continuous telemetry monitoring occurred for all patients.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0395.


50321

Based on observation, interview, record review and policy review, the hospital failed to ensure:
- Four current patients (#19, #35, #36 and #37), of four patients observed, were provided psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) after being placed on suicide (thoughts of causing one's own death) precautions.
- Staff followed policies and procedures when one to one (1:1, continuous visual contact with close physical proximity) observations were not implemented and documented for two current high-risk suicidal patients (#19 and #35), of four patients observed; and
- One current patient (#36), of four patients observed, was properly assessed by a provider after being placed on suicide precautions.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 06/04/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on the assessment and observation of patients placed on suicide precautions. All remaining staff were educated prior to the start of their next shift.

Review of hospital policy titled, "Suicide and Homicide Precautions Acute Care," dated 08/27/24 showed:
- A suicide risk assessment was completed upon admission. If the patient answers "yes" to any of the questions, the nurse would initiate suicide precautions.
- All patients placed on suicide precautions required continuous visual observation while receiving medical treatment. Any patient known or suspected to be suicidal should be evaluated by a psychiatrist or by a psychiatric evaluation nurse within 24 hours.
- Patients were to be under continuous observation by a patient sitter or another co-worker from the unit assigned.
- The provider should be notified immediately when a patient responded positive for any risk factor resulting in need for suicide precautions. An order must be obtained.
- All items that could pose a ligature or self-harm risk should be removed from the patient's room.
- The nurse should complete the room safety check every shift, round on the patient every hour and document if the patient is on suicide precautions.
- All individuals on suicide precautions were considered a high risk for elopement. The charge nurse, a nurse leader, and public safety should be notified of the risk.
- Patients on suicide precautions should have the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) assessment daily.
- A notification to the physician should be completed for any change of condition.

Review of an untitled, undated, hospital document with a yellow note attached stating, "Checklist for Room Safety," identified items that have potential to cause harm to self or others. The items included were chemicals, cleaning products, hangers, bins, artwork not solidly secured to wall, sharps, plastic liners in trash carts, cord, phones, intravenous (IV; in the vein) equipment, pumps, tubing, call light, oxygen/medical gas valve adapter trees, suction canisters and tubing and hand sanitizer. These items should be removed from patient rooms for safety.

Review of the undated hospital document titled, "Sitter Precautions Table," showed:
- Nurses should round and document every hour on patients with suicide and self-harm precautions.
- Sitter documentation should be completed every 15 minutes.
- All items that are considered a safety risk, including plastic bags and all unused equipment should be removed from the room.

Review of an undated hospital document titled, "Safety Data Sheet," showed Purell Hand Sanitizer contains hazardous ingredients including Ethyl Alcohol and Isopropyl Alcohol. If swallowed, medical attention should be obtained.

Observation on 06/02/25 at 10:10 AM, in Patient #19's room showed:
- Staff Y, Patient Care Technician (PCT), was assigned as the 1:1 continuous observer.
- Oxygen tubing was hanging off the wall and was not currently in use.
- An IV pump and cord sitting next to the patient bed and was not currently in use.
- Three metal clothing hangers in an unlocked closet.
- A wall mounted hand sanitizer containing 1200 milliliter (ml) of hand sanitizer.
- Two red cords, approximately three feet in length, located in the bathroom.

Review of Patient #19's medical record showed he was admitted on 06/01/25 after an attempted suicide. He was placed on suicide precautions and assigned a 1:1 sitter. There was no 1:1 documentation on the night shift of 06/02/25 through 06/03/25.

During an interview on 06/02/25 at 10:10 AM, Staff Y, PCT, stated she completed the safety checklist and documented that Patient #19's room was safe. Everything had been removed that posed a concern for the patient's safety.

During an interview on 06/02/25 at 10:12 AM, Staff AA, Clinical Supervisor, stated that sitter documentation should be completed every 15 minutes and included an assessment of the patient's room for safety.

Observation on 06/03/25 at 12:55 PM, in Patient #35's room, showed:
- Staff AAA, Sitter, was at the bedside and assigned to monitor Patient #35.
- Two six-ounce unopened bottles of Hibiclens (antimicrobial soap) sitting on the counter.
- Two four-ounce tubes of petroleum jelly sitting on the counter.
- An oxygen/medical gas valve adapter tree on the wall, not in use.
- A suction valve and container on the wall, not in use.
- A wall mounted hand sanitizer containing 1200 ml of hand sanitizer.
- A corded lamp on the bedside table
- An unsecured picture on the wall.
- A Workstation on Wheels (WOW) with a hand scanner that in the room, not in use.
- Two red cords, approximately three feet in length, in the bathroom.
- A large, non-breakaway privacy curtain, not in use.

Review of Patient #35's medical record showed:
- He was admitted on 05/31/25 after ingesting hand sanitizer and multiple pills in a suicide attempt.
- He was placed on suicide and elopement precautions.
- On 05/30/25 & 05/31/25, 1:1 observations were only documented from 7:00 AM through 6:00 PM. No documentation was provided for the overnight shift.
- No daily safety checklists were documented.

Observations on 06/03/25 at 12:40 PM, in Patient #36's room, showed:
- A roll of plastic trash bags sitting on the counter.
- A plastic bag in the trash can sitting next to Patient #36.
- Two red cords, approximately three feet in length, in the bathroom.
- A plastic bag in the soiled laundry basket.
- Multiple bottles of body wash and Hibiclens (an antibacterial, antimicrobial skin cleanser) on the bathroom counter.
- An IV pole, next to the patient's bed, not being used.
- A suction regulator tree sitting on a shelf in the closet.
- A leg compression machine with attachment cords approximately two feet long, sitting on a shelf in the closet.
- A wall mounted hand sanitizer containing 1200 ml of hand sanitizer.

Review of Patient #36's medical record showed he was admitted on 05/30/25 for acute encephalopathy due to an intentional drug overdose and alcohol intoxication. Only one daily safety checklist was documented on 05/30/24 at 11:00 PM. There were no additional safety checklists.

During an interview on 06/03/25 at 1:15 PM, Staff BBB, Registered Nurse (RN), stated that there should be documentation every 15 minutes for all patients on suicide precautions.

During an interview 06/03/25 at 12:50 PM, Staff OO, Charge RN, stated that safety checklists should be completed every shift by the nurse and that there should be documentation every two hours on visual assessments of patients on suicide precautions.

Review of Patient #37's medical record, and concurrent observation, on 06/03/25 at 1:10 PM showed:
- He was admitted for low blood pressure and had a history of a brain injury.
- On 06/01/25 at 7:37 PM, nursing documentation indicated that Patient #37 was suicidal, and they had concerns for his risk for violent behaviors. He was placed on suicide precautions. Documentation indicated that the patient in "Bed 2 stated Patient #37 wanted to kill himself and was already dead on the inside." Only one C-SSRS was completed.
- After the initiation of suicide precautions, there was no documentation that the physician or charge nurse were notified of his change in condition.
- There was no physician order for suicide precautions or daily checklists completed.

During an interview on 06/03/25 at 1:30 PM, Staff NN, Nurse Manager, stated:
- He unaware that Patient #37 had been placed on suicide precautions. Policy dictated that he should have been notified.
- The physician should have been notified and an order obtained within 24 hours of placing the patient on suicide precautions.
- There was no documentation made by the nursing staff to show an assessment of the patient every two hours.

During an interview on 06/04/25 at 9:30 AM, Staff VVV, Director of Nursing (DON), stated:
- A C-SSRS and a safety checklist should be completed by nursing staff every shift.
- All 1:1 observations should be documented every 15 minutes by the assigned staff member.
- The patient's assigned nurse is responsible for ensuring the 15-minute documentation has been completed, the patient's room is safe, and all hazards have been removed.
- The nurse should assess patients on suicide precautions every two hours.

During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Executive Nursing Director, stated:
- A physician's order should be obtained for suicide precautions and the physician should be notified of any changes to the patient's safety and well-being.
- All patients placed on suicide precautions should have a 1:1 sitter with them at all times.
The sitter must document every 15 minutes.
- The assigned nurse for patients on suicide precautions should ensure a safe room environment and complete a safety checklist each shift and verify that the sitter documented every 15 minutes.
- All hand sanitizers should be removed from the patient rooms of those on suicidal precautions.


41865

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for one Emergency Department (ED) discharged patient (#41) of one discharged ED patient reviewed and all current ED continuous telemetry monitored patients.
- Ensure the assigned nurse rounded every hour and documented the rounding in the electronic health record (EHR) for four current patients (#19, #35, #36, and #37) out of four current patients observed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm).
- Ensure appropriate nursing assessments were completed and documented on three current patients (#19, #36, and #37) out of four current patients on SP.
- Ensure that physician notification, appropriate consults and orders were obtained, when one patient (#37) had a significant change in a risk for suicide out of four current patients on SP observed.
- Ensure that nursing documentation for one to one (1:1, continuous visual contact with close physical proximity) observations were completed on two current suicidal patients (#19 and #35) out of four current patients on SP observed. (A-0395)

Finding included:

Review of the hospital's document titled, "Cardiac Monitoring and Telemetry, Adult," dated 04/27/23, showed the policy applied to inpatient continuous telemetry monitoring and the ED followed a separate policy. A cardiac monitor technician was assigned to watch the telemetry monitor 24 hours a day when a continuous telemetry monitor was in use.

Review of the hospital's document titled, "Cardiopulmonary (related to the heart and lungs) Monitoring in the Emergency Trauma Center," dated 05/04/2021, showed no designated individual was assigned to continuously monitor patients with a telemetry monitor.

Review of the hospital's document titled, "Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) Summary," dated 12/19/24, showed on 12/02/24 at 6:33 PM, Patient #41 was found on the floor without his telemetry monitor on. He was pulseless (normal pulse/heartbeats for adults range from 60 to 100 per minute) and a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was initiated. At 6:49 PM, he expired. Review of the medical record showed he had been off the telemetry monitor since 5:30 PM. Recommended actions related to the event were to reach out to other facilities to determine how patients on telemetry were monitored, and for staff to place the telemetry monitor on standby when not in use.

Review of Patient #41's medical record showed:
- He was a 63-year-old male who arrived at the ED, on 12/02/24 at 11:55 AM, with a chief complaint of shortness of breath.
- At 11:59 AM, continuous cardiac telemetry monitoring was ordered.
- At 12:00 PM, nursing documentation indicated he was placed on a telemetry monitor.
- At 5:30 PM, vital signs (VS, measurements of the body's most basic functions) were obtained.
- At 6:33 PM, nursing documentation indicated he was found lying on the floor face up, behind the bed. A code blue was initiated.
- At 6:49 PM, he expired.

During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Nursing Executive Director, stated that she expected staff to ensure patients were connected to a telemetry monitor when ordered. Staff should check on patients when they became disconnected from their telemetry monitor. Following patient #41's event she reached out to other hospitals and found they did not have central monitoring for their ED telemetry patients. Their inpatient units with telemetry patients were continuously monitored by a cardiac monitor technician in their central monitoring area.

During an interview on 06/04/25 at 1:00 PM, Staff XX, ED Director of Nursing (DON), stated that the telemetry monitors in the ED were not centrally monitored. The telemetry monitor screens were located in specific nursing station areas, near each ED room. The screens were not visible throughout the entire ED. When Patient #41 was found, he had been off the telemetry monitor for one hour. His nurse was unaware he was disconnected from the telemetry monitor and was with another patient. No one had been at the nursing station to observe the alarm. Staff were expected to be aware of the alarms, and it was preferable for a staff member to be at the nursing station. There was no expectation for a dedicated staff member to always be at the nurses' station to view the telemetry monitors. It was possible that no one would be present to observe or respond to alarms since there was not a dedicated cardiac monitor technician. The ED currently had 18 patients with continuous telemetry monitor orders.

During an interview on 06/03/25 at 1:40 PM, Staff NN, Registered Nurse (RN), stated that she found Patient #41 on the floor at 6:30 PM, with his telemetry monitor disconnected. The last set of recorded VS were at 5:30 PM. After 5:30 PM, there was no recorded data in the HER, indicating that the telemetry monitor had been disconnected. She had been in another patient's room and was not aware that Patient #41's telemetry monitor had been disconnected.

Review of hospital policy titled, "Suicide and Homicide Precautions Acute Care," dated 08/27/24 showed:
- A suicide risk assessment was completed upon admission. If the patient answers "yes" to any of the questions, the nurse would initiate suicide precautions.
- All patients placed on suicide precautions required continuous visual observation while receiving medical treatment. Any patient known or suspected to be suicidal should be evaluated by a psychiatrist or by a psychiatric evaluation nurse within 24 hours.
- Patients were to be under continuous observation by a patient sitter or another co-worker from the unit assigned.
- The provider should be notified immediately when a patient responded positive for any risk factor resulting in need for suicide precautions. An order must be obtained.
- All items that could pose a ligature or self-harm risk should be removed from the patient's room.
- The nurse should complete the room safety check every shift, round on the patient every hour and document if the patient is on suicide precautions.
- All individuals on suicide precautions were considered a high risk for elopement (when a patient makes an intentional, unauthorized departure from a medical facility). The charge nurse, a nurse leader, and public safety should be notified of the risk.
- Patients on suicide precautions should have the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) assessment daily.
- A notification to the physician should be completed for any change of condition.

Review of the undated hospital document titled, "Sitter Precautions Table," showed:
- Nurses should round and document every hour on patients with suicide and self-harm precautions.
- Sitter documentation should be completed every 15 minutes.
- All items that are considered a safety risk, including plastic bags and all unused equipment should be removed from the room.

Review of Patient #19's medical record, and concurrent observation, on 06/02/25 at 10:15 AM, showed:
- He was admitted on 06/01/25 after he overdosed on acetaminophen (pain medication, also used to reduce fever) in a suicide attempt and was placed on SP.
- One C-SSRS assessment was completed on 06/01/25. No other C-SSRS assessments were documented.
- The nurse failed to ensure the 1:1 sitter observations were completed every 15 minutes, and the hourly safety checks were not documented.

Review of Patient #35's medical record showed he was admitted on 05/31/25 after he ingested hand sanitizer and multiple pills in a suicide attempt and was placed on SP and elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury). The nurse failed to ensure the sitter's 1:1 observations were completed every 15 minutes and hourly safety checks were not documented.

Review of Patient #36's medical record showed:
- She was admitted on 05/30/25 for encephalopathy (damage or disease that affects the brain) due to alcohol intoxication and an intentional drug overdose.
- She had multiple suicide attempts within the last several months, the most recent being two weeks prior.
- One C-SSRS assessment was completed on 05/31/25. There were no other daily C-SSRS assessments completed.
- Hourly safety checks were not documented.

Review of Patient #37's medical record, and concurrent observation, on 06/03/25 at 1:10 PM showed:
- He was admitted for low blood pressure and had a history of a brain injury.
- On 06/01/25 at 7:37 PM, nursing documentation indicated that Patient #37 was suicidal, and they had concerns for his risk for violent behaviors. He was placed on suicide precautions. Documentation indicated that the patient in "Bed 2 stated Patient #37 wanted to kill himself and was already dead on the inside." Only one C-SSRS was completed.
- After the initiation of suicide precautions, there was no documentation that the physician or charge nurse were notified of his change in condition.
- There was no physician order for SP and daily checklists were not completed.
- There were no orders for a clinical hold or psychiatry (the study and treatment of mental illness) consult.
- Hourly safety checks and C-SSRS shift assessments were not documented.

During an interview on 06/03/25 at 1:15 PM, Staff PP, Sitter, stated Patient #37 had been on constant 1:1 observation for SP since 06/01/25.

During an interview on 06/03/25 at 1:30 PM, Staff NN, Nurse Manager, stated if a patient was placed on SP, the manager of the unit, and the physician should be notified. An order for SP should be obtained within 24 hours of placing a patient on SP. He indicated there was no documentation made by the nursing staff to show a suicide safety assessment of the Patient #37 was completed every two hours per policy.

During an interview on 06/02/25 at 10:12 AM, Staff AA, Clinical Supervisor, stated that sitter documentation should be completed every 15 minutes and included an assessment of the patient's room for safety.

During an interview on 06/03/25 at 1:15 PM, Staff BBB, RN, stated that there should be documentation every 15 minutes for all patients on SP. The nurse was to document every two hours and was responsible to ensure the sitter was documenting the 1:1 observations every 15 minutes.

During an interview on 06/04/25 at 9:30 AM, Staff VVV, DON, stated:
- A C-SSRS and safety checklist should be completed and documented every shift by the assigned nurse.
- All 1:1 observations should be documented every 15 minutes.
- The nurse was responsible to ensure the sitter documented the 1:1 observations on SP patients every 15 minutes.
- The nurse was responsible for assessing patients on SP every two hours and was to ensure that they were in a safe room environment, with all potential hazards removed.

During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Executive Nursing Director, stated:
- All patients that were placed on SP should have a 1:1 sitter with them at all times and a physician's order should be obtained.
- The sitter must document their observations every 15 minutes.
- The nurse should ensure that the 1:1 observations were documented every 15 minutes, that the room was safe, and a safety checklist was completed each shift.
- The nurse should notify the physician if there were any pertinent changes to the safety and well-being of all patients immediately.






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