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A. Based on document review, interview, and observation, it was determined that the Hospital failed to protect and promote patients' rights by failing to ensure that care was provided 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 provide care in a safe setting by failing to complete observation rounds, as required. See deficiency cited at A-144 A.

2. The Hospital failed to ensure the BHU was ligature free. See deficiency cited at A-144 B.

3. The Hospital failed to ensure the ligature alarm was monitored. See deficiency at A-144 C.

4. The Hospital failed to ensure appropriate observation precautions were in place. See deficiency at A-144 D.

A. Based on document review, interview, and observation, it was determined that for the 8 patients on the general behavioral health unit's census who did not have one to one sitters on 3/3/2023, the Hospital failed to provide care in a safe setting by failing to complete observational rounds every 15 minutes, as required.

Findings include:

1. The Hospital's policy titled, "Monitoring of Psychiatric Patients" (revised 8/2021) was reviewed and required, "...7. Patients hospitalized in the psychiatric unit will be placed on every 15-minute rounds, i.e. visually monitored every 15 minutes during their admission."

2. The Hospital's policy titled, "Hall Monitoring and Physical Safety" (revised 2/2020) was reviewed and required, "...1. Caregivers assigned to monitor the hallway: B. Maintain physical view of hallways and report any observations to the caregiver assigned to rounds or the caregiver in the nurse's station ... F. Pays close attention to all blind spots on the unit ... 3. It is the responsibility of the charge nurse to ensure that a hall monitor is always assigned to be in the hall."

3. The clinical record of Pt. #1 was reviewed on 03/15/2023. Pt. #1 was admitted on 2/28/2023 with a diagnosis of suicidal ideation. The patient expired on 3/3/2023 due to apparent suicide. Pt #1 was on every 15 minute observations. The clinical record included the following:
-Observation Flow sheet, dated 3/3/2023, indicated that the 15-minute rounds were being completed. However, during review of the video footage, it was determined that the 15-minute rounds were not conducted on 3/3/2023 from 4:00 PM to 5:00 PM.
-Daily Progress Note by physician who responded to code, dated 3/3/2023 at 5:03 PM, included, "Code blue called at 5:03 PM, arrived (code blue team) 5:05 PM, CPR (cardiopulmonary resuscitation) per ACLS (advanced cardiovascular life support) protocol already underway. Per report, patient was found unresponsive, apneic (absence of breathing), asystole (cessation of electrical activity of heart) upon arrival ... Code ended at 5:35 PM, at which time (Pt. #1) was pronounced deceased."

4. On 3/16/2023, the general behavioral health unit census and assignments from 3/3/2023 was reviewed. There were 10 patients on the unit. Two of the patients were on 1:1 observation with sitters assigned to them. The other eight (8) patients were on every 15 minute observations, with 2 of these patients (Pt #6 and Pt #7) being on suicide precautions.

5. The clinical records for the patients (Pt #6 and Pt #7) who were on suicide precautions were reviewed for rounding documentation on 3/3/2023. The rounding flowsheets (dated 3/3/2023) included completion of observational rounds every 15-minutes. On 3/15/2023, video footage dated 3/3/2023 from the BHU noted that rounds were not conducted between 4:00 PM and 5:00 PM.

6. On 3/15/2023 at approximately 11:20 AM, the Hospital's video footage for 3/3/2023 from the BHU Northeast hallway view was reviewed with the BHU Manager (E #1). The video footage showed the following:

-4:00 PM to 4:20 PM, a MHT -Mental Health Technician (E #8) assigned to conduct the 15-minute rounds was observed sitting by the nurse's station.
-4:16 PM, a MHT (E #6) assigned to conduct hall monitoring, was observed walking in the NE (northeast) hallway then returned to the nurse's station, an RN (E #9) observed at nurse's station at this time.
-4:26 PM, (E #8) walking down Northeast hallway, passes by patient rooms, some with doors closed including room 309 (Pt. #1's) room without opening the doors to observe patients, and returns to nurse's station.
-4:30 PM, sitter observed at room 307 in NE hallway, near room 309. (E #8) across from nurse's station speaking with a patient.
-4:35 PM, an RN (E #7) in view, observed deactivating the alarm at the NE hallway entrance corridor, then goes into room 305 (first patient room down the hall fron the entrance corridor). (E #8) walks down NE hallway, (E #8) seen deactivating an alarm by room 309 and walks away from room.
-4:56 PM, (E #7) walks from the area of nurses' station down NE hallway to dispense medications at room 309, comes out of room and motions to staff to come to room 309.
-4:57 PM, (E #6) and other staff come to room 309, other staff seen bringing crash cart to 309.
From 4:00 PM to 4:56 PM, no staff was observed conducting the 15-minute rounds at 4:00 PM, 4:15 PM, 4:30 PM and 4:45 PM.

7. On 3/15/2023 at 11:45 AM, an interview was conducted with the Unit Manager (E #1). E #1 confirmed that the video footage indicated that the 15 minute rounds were not being conducted as required.

B. Based on document review, observation, and interview, it was determined that for 1 of 1 Behavioral Health Unit (BHU), the Hospital failed to ensure care in a safe setting due to the presence of ligature risks on the Behavioral Health Unit.

Findings include:

1. On 3/15/2023, the CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. On 3/15/2023, the Hospital's Environmental Assessment, dated 3/14/2023 was reviewed and included, "Thermostats ...Status - work order to change out wall mounted thermostats ..."

3. On 3/20/2023, the Hospital's policy titled, "Monitoring of Psychiatric Patients" (revised 8/2021) was reviewed and indicated, "...This policy provides staff with guidelines on type and frequency of patient monitoring and observation on the psychiatric unit..." The policy did not require room entrance doors to be kept open or locked when not in use on the psychiatric unit, and lacked any patient safety measures to mitigate the ligature risk posed by the patient room entrance doors.

4. On 3/15/2023 between 9:00 AM and 10:00 AM, an observational tour was conducted on the BHU. There were no patients in the BHU. The general BHU included rooms 304 to 313, and the ITU (intensive therapy unit) included rooms 321 A, B, C, D and E. The following ligature risks were observed during tour:
- Rooms 305, 307, 308, 313, and outside of room 304 contained hard plastic boxes covering the thermostats which were approximately 8 inches x 4 inches, and protruded from the wall approximately 4 inches. There were approximately ½ inch deep by approximately 8- inch-long concave spaces along the length of the top where the cover meets the wall that could be used as an anchor point.
- All of the patient room entrance doors and door frames were square, and the doors reached the top of the door frames. (The bathroom doors and door frames in the patient rooms were also square and reached the top, but were all equipped with ligature alarms.)
During the tour, the Manager of the Behavioral Health Unit (E #1) stated that patients were allowed to keep their room entrance doors closed while the patients were in their rooms.

5. On 3/15/2023, the Hospital's video footage of the general behavioral health unit, dated 3/3/2023 from 4:00 PM - 5:10 PM , was reviewed. The video footage noted that Pt #1's (room 309) door was closed prior to Pt #1 committing suicide with a sheet around his neck hanging from the bathroom door, along with multiple other patients' room entrance doors, which were observed to be closed during this time.

6. On 3/15/2023 at 9:55 AM, an interview was conducted with the Vice President of Facilities (E #4). E #4 stated that the thermostat boxes are going to be removed.


C. Based on document review, observation and interview, it was determined that for 2 of 2 staff (1 Mental Health Worker - E #8 and Registered Nurse [RN]- E #7) on the general BHU, the Hospital failed to ensure the appropriate response to the ligature alarm system, as required.

Findings include:

1. On 3/16/2023, the Hospital's policy titled, "Clinical Alarm Management" (dated 2/2021) was reviewed and indicated, " Caregivers should not bypass, shut off or adjust alarm volumes to a level that cannot be readily heard or seen when the alarm activates ...Procedure -Nursing staff should monitor clinical alarms that are located at the bedside ..."

2. On 3/15/2023, the video footage dated 3/3/2023 from 4:00 PM until 5:00 PM on the BHU was reviewed and noted that E #7 and E #8 did not respond to the ligature risk alarm in Pt #1's room. At 4:35 PM, RN (E #7) in view, at NE hallway entrance corridor was observed deactivating an alarm, then goes into room 305. (E #8) walks down NE hallway, (E #8) seen deactivating an alarm by room 309 and walks away from room without entering the room. E #8 was observed disabling the alarm by turning the key outside Pt #1's room but did not go inside Pt #8's room to assess Pt #8's condition.

3. On 3/15/2023 at 2:00 PM, an interview was conducted with a Mental Health Technician (MHT/E #6). E #6 stated that on 3/3/2023, E #6 was assigned to monitor the hall during the time that (Pt. #1) was found hanging in his room. E #6 stated that he did not hear any alarms. E #6 stated that staff have been "taping down the alarm button at the nurses' station for as long as I can remember."

4. On 3/16/2023 at 11:30 AM, an interview was conducted with a Registered Nurse (RN/E #7). E #7 stated that on 3/3/2023, E #7 did not hear an alarm, prior to finding (Pt. #1) during medication pass at around 5:00 PM.

5. The MHT (E #8) who deactivated the alarm at Pt #1's room in the video was unavailable for interview.

6. On 3/15/2023 at 11:45 AM, an interview was conducted with the Unit Manager (E #1). E #1 stated that E #7 and E #8 should have assessed Pt #1 before disabling the ligature risk alarm system.

D. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) patient presenting with suicidal ideation (SI), the Hospital failed to provide care in a safe setting by failing to ensure appropriate observation precautions were in place.

Findings include:

1. The Hospital's policy titled, "Monitoring of Psychiatric Patients" (revised 08/2021) was reviewed and required, "III. Monitoring for Safety Precautions. 1. Patients on the Psychiatric Unit with orders for safety precautions will be observed as follows: a. Suicide Precautions: All patients will be evaluated for suicidality using the Columbia Suicide Severity Rating Scale (C-SSRS). Depressive Mood ... Helplessness/Hopelessness ... Social withdrawal ... The C-SSRS is to be completed for all new admissions. If the assessment indicates a risk, the patient is to be placed on safety precautions ... Patients on safety precautions are monitored for behaviors associated with that precaution ..."

2. The clinical record of Pt. #1 was reviewed on 03/15/2023. Pt. #1 was admitted on 2/28/2023 with a diagnosis of suicidal ideation. The patient expired on 3/3/2023 due to apparent suicide. The clinical record included the following:
-Psychiatric Triage Assessment (completed in the emergency department), dated 2/28/23 at 9:29 PM, included, " ... ED (emergency department) for endorsing SI and AH (auditory hallucinations) states [Pt #1] is feeling suicidal for a couple of days ... has a plan to take a lot of street drugs.
-Pt #1 was admitted to the Behavioral Health Unit on 2/28/2023. The BH (Behavioral Health) Admission note, dated 2/28/23 at 11:35 PM, included, " ... Isolative." Pt #1 was placed on close observation, requiring 15 minute checks.
-Psychiatric Admission Assessment, dated 3/1/2023 at 8:15 AM, included, "(Pt.#1) states ... is depressed/suicidal. States ... would take drugs. Pt states [Pt #1] left NH (nursing home) yesterday and was on the street. States ... is hearing voices, unclear what they are saying. Pt. gives hx (history) of prior [suicide] attempts. Unclear if taking meds ... Plan: Continue with inpatient psychiatric hospitalization ... precautions per unit protocol (close observation, every 15-mintue rounds)."
-The suicide risk assessments using the C-SSRS (Columbia Suicide Severity Rating Scale), dated 2/28/2023 and 3/1/2023, indicated that Pt #1 was a "Moderate Risk" for suicide. However, Pt #1 was not placed on suicide precautions.

3. On 3/21/2023 at 8:15 AM, a telephone interview was conducted with the Attending Psychiatrist (MD #1). MD #1 stated he is not sure why (Pt. #1) was not on suicide precautions after arriving on the unit from the ED. The patient was placed on standard every 15-minute rounding. The patient was not presenting with signs of suicide. Based on the patient's assessments, suicide precautions were not indicated for Pt #1.