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Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video's and review of incidents and internal investigations that occurred on the Behavioral Health Unit (BHU); the facility: 1) failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk for self harming behaviors and or potential harm to other patients due to destroying hospital property; 2) failed to ensure nursing staff were maintaining a safe, calm therapeutic environment for the care of psychiatric patients by utilizing techniques to de-escalate patients, implementing safety plans, providing medications, utilizing seclusion and/or restraints to ensure the patients were safe from self harm or destruction of property; and 3) failed to provide nursing supervision of patient care for 4 of 10 sampled patients (Patients 3, 2, 4, and 5). These failures resulted in 1 patient (Patient 2) kicking the window until breaking the lock and opening the window, climbing out on the ledge for 3 minutes and returning inside without staff detection on 10/30/17 [note: this was a window on the fifth floor of the facility]; 1 patient (Patient 3) destroying property,breaking and using a light bulb to self harm by cutting bilateral arms and neck without being detected and taking a cigarette lighter from a visitor's jacket, burning a pencil before placing it under (gender) mattress and putting burn marks on the wall in (gender) room; 1 patient (Patient 4) had a pair of shorts with a tie string at the waistband, which pt removed and string was not found; and 1 patient (Patient 5) was found sitting on the bed with hoodie sleeves wrapped around (gender) neck and had also made superficial lacerations to left inner wrist. The failure to provide supervision and maintain a safe environment had the potential for other patients on the Behavioral Health Unit to sustain an injury/death. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed and had been ongoing at this facility since 10/30/17, posing a threat of potential serious injury, harm, impairment or death of patients admitted with psychiatric diagnosis and risk factors. The administrator was informed of the IJ determination by the State Agency [SA] on 4/24/18 at 10:30 AM. The total sample size was 10. The facility census was 77.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediacy on 4/25/18 at 11:15 AM by implementing the following:

-Effective immediately (4/24/18) arrangements were made for a Behavioral Health consulting team to travel and arrive at the facility. The consulting team arrived at 4:10 PM on 4/24/18 and immediately started a risk assessment of the BHU.
-Administrative Staff conducted a departmental tour of the BHU. At 4:30 PM policy and procedures were reviewed with assistance of the consulting team member with current focus on visitation, suicide precautions, and escape precautions.
-The facility environmental services staff removed the 15 wall sconce lights in patient rooms, removed the toilet paper dispensers, adapted the paper towel dispensers, placed shatterproof film sheeting on all windows on the psychiatric unit, and removed all furniture that was not weighted and could be picked up by patients.
-Administrative Staff contacted the dietary department and discontinued the use of ceramic dishes and metal silverware and implemented the use of styrofoam dishes and plastic forks and spoons.
-Beginning 4/24/18, all staff currently working on the BHU and prior to assuming any shifts on the BHU received training on a packet of items and policies, including sign-off sheets.
-Beginning 4/24/18, the reinforcement of the requirement for 15 minute checks and corresponding documentation of face-to-face checks are being done.
-Beginning 4/24/18, Seclusion and restraint practice and documentation policy and procedure was reviewed and staff re-education completed before assuming their next shift.
-A visitation policy was completed and approved by the Chief Nursing Officer (CNO) and the Chief Medical Officer (CMO) and will be implemented by 4/27/18 to avoid future issues with contraband items.
-The Leadership team will be present on the BHU 24/7 for support, coaching and monitoring through the immediate period of stabilization of processes and consultant recommendations.
-Current admissions to the BHU were suspended for 48 hours until another risk assessment with the BHU Consulting Team, Administrative Staff and the Medical Director deemed the environment is safe and supervision is provided.
-Compliance audits will be managed by the Executive Director of Quality; this will include ensuring adequate volumes and time frames for audits, review of audits, review of results, and departmental accountability and plans for correction are completed.
-The development of a report to communicate the progress of the action items and audit results for monthly updates.

Refer to A 144.

Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video's and review of incidents and internal investigations that occurred on the Behavioral Health Unit (BHU); the facility: 1) failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk for self harming behaviors and or potential harm to other patients due to destroying hospital property; 2) failed to ensure nursing staff were maintaining a safe, calm therapeutic environment for the care of psychiatric patients by utilizing techniques to de-escalate patients, implementing safety plans, providing medications, utilizing seclusion and/or restraints to ensure the patients were safe from self harm or destruction of property; and 3) failed to provide nursing supervision of patient care for 4 of 10 sampled patients (Patients 3, 2, 4, and 5). These failures resulted in 1 patient (Patient 2) kicking the window until breaking the lock and opening the window, climbing out on the ledge for 3 minutes and returning inside without staff detection on 10/30/17 [note: this was a window on the fifth floor of the facility]; 1 patient (Patient 3) destroying property,breaking and using a light bulb to self harm by cutting bilateral arms and neck without being detected and taking a cigarette lighter from a visitor's jacket, burning a pencil before placing it under (gender) mattress and putting burn marks on the wall in (gender) room; 1 patient (Patient 4) had a pair of shorts with a tie string at the waistband, which pt removed and string was not found; and 1 patient (Patient 5) was found sitting on the bed with hoodie sleeves wrapped around (gender) neck and had also made superficial lacerations to left inner wrist. The failure to provide supervision and maintain a safe environment had the potential for other patients on the Behavioral Health Unit to sustain an injury/death.

These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed at this facility since 10/30/17, posing a threat of potential serious injury, harm, impairment or death of patients admitted with psychiatric diagnosis and risk factors. The administrator was informed of the IJ determination by the State Agency [SA] on 4/24/18 at 10:30 AM. The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 4/25/18 at 11:15 AM. The total sample size was 10. The facility census was 77.

Findings are:

A. A review of Patient 3's current medical record revealed that the patient is a 14 year old admitted to the BHU [on 4/1/18 from the emergency department] following a suicide attempt by multiple cuts to the left entire arm requiring sutures. The patient had just been discharged from the BHU following inpatient treatment 3/23/18-3/31/18. The patient had developed a Patient Safety Plan on 4/1/18 which identified the patient's triggers for high risk behavior as "I Don't Know" and identified soothers for high risk behaviors as draw, watch television and talking.

A review of the Root Cause Analysis and Nursing Progress Notes for Patient 3 revealed:
-On 4/10/18 at 10:40 AM - Housekeeping reported "Ashes were found in the patient's shower indicating (gender) had been smoking. Upon further investigation, it was revealed (gender) had 3 pencils with burns under the mattress, burns on the wall and had 3-4 small burns on knee. [Review of video footage shows patient got the lighter and cigarettes out of (parent's) jacket during a visit earlier that day when the patient's parent went into the patient's room during their visit."] On 4/10/2018, the patient became agitated and jumped off a chair in the common room bending ceiling frame, threw the trash can, threw and broke the VCR and threw and broke the sound bar. An order was received and Patient 3 placed in seclusion. Followed by an order for 1:1, which was discontinued 4/12 at 11:17 AM.
-Per the nurse Progress notes [dated 4/10/18 at 1:33 PM], "Patient ripped the exit sign from the ceiling, started throwing chairs around in social area. Patient was asked to go back to seclusion and did cooperatively. Patient was given 1 mg (milligram) of Ativan.
-4/12/18 Patient became agitated and tore down curtains, threw a chair at a window, damaged the wall sconce in (gender) room, and broke a shard of plastic off the wall sconce. The patient was placed in a physical hold, chemical restraint administered (The patient was given 1 mg of Ativan (anti-anxiety medicine) intramuscularly. NOTE: Nurses misinterpreted the definition of a chemical restraint), and was moved to a different room due to the broken light. Patient was also placed in seclusion.
-4/13/18 Patient was in (gender) room, 15-minute check was overdue. The RN (registered nurse) noticed the door to the room was closed. RN went to open the door to remind the pt it needed to be kept open. RN found blood on the floor of the room and patient in the bathroom with multiple self-inflicted cuts to the neck and bilateral forearms. Upon investigation, it was discovered pt had broken another wall sconce, removed the light bulb, wrapped it in paper towel, broke the bulb and used it to cut self approximately 25-30 times on neck and bilateral forearms. The facility investigation revealed that a therapist left room at 12:56 PM and RN found pt in room with cuts at 1:31 PM; counselor had talked to pt about a topic that caused significant agitation.

A review of the facility security video on 4/10/2018 for Patient 3 revealed:
- At 10:33 AM Patient 3 was flipping a elastic hair tie in air, laying on back on couch in the commons room, pacing around the commons area. At 11:08 AM Patient 3 picked up the board games, DVD player, sound bar and threw them onto the floor, breaking the DVD player and sound bar. There were 7 staff members within the frames of the video and no one intervened during this time, it could be seen that 1-2 staff were talking to Patient 3.
- At 11:09 -11:10 AM the patient was walked to the seclusion room. While in the seclusion room the patient ripped the mattress cover and tore the foam mattress, before staff removed it.
- At 11:25 AM the patient was given a shot of medication. At 11:38 AM the patient was taken out of seclusion.
- At 12:18 PM patient 3 was served lunch in the commons area, the tray had ceramic dishes and stainless steel silverware.
- At 1:32 PM Patient 3 stood on the couch and jumped off grabbing the fire exit sign and ripping it out of the ceiling causing other debris to fall from ceiling. At 1:33 PM Patient 3 threw a glass of water at the camera. At 1:33-1:34 PM, the patient picked up a chair and swung it 4-5 times before releasing it and it flew across the room. There were 4 staff members within the frames of the video and no one intervened during this time. The patient was returned to seclusion following this behavior.

A review of the following facility incident reports related to Patient 3 revealed:
-On 4/12/18 at 7:30 PM - Patient 3 "was extremely agitated. Tore down the curtains, throwing chair at the windows and walls, then damaged the wall scone light and broke a shard of plastic off of it. At that point staff and security placed the patient in a physical hold to prevent (gender) from using the shard to cut self. (Gender) struggled briefly and was released within 5 minutes. A chemical restraint had been ordered. Was cooperative with the administration of the medication. It was necessary to move patient to a different room d/t (due to) the damaged light."
-On 4/13/18 at 1:31 PM - Patient 3's "door was observed to be closed, upon opening door, to remind patient to keep door open, noticed some drops of blood on the floor, then noticed the patient in (gender) bathroom bleeding from bilateral forearms and slightly from the neck area. Patient didn't say a word or respond to any immediate questions asked. Patient later reported that (gender) used a hook from the curtains to pull down the nightlight cover that was missing a screw to gain access to the light bulb. The patient then wrapped the bulb in a paper towel to break it, before cutting self. Security, provider, house supervisor, and BHU manager notified. Arms and wound cleaned by house supervisor, surgical consult ordered and the wounds were covered by telfa and wrapped with [guaze]. Patient placed into open area of pod, with 1:1 staff supervision including bathroom use and bathing.
-On 4/22/18 at 2:22 PM - Patient 3 "was offered group with (therapist), patient refused. (Therapist) advised patient "okay" grabbed the remote to the television and turned off the television. Patient sat quietly. Later (therapist) sitting down charting and the patient stands up starts yelling telling (therapist) "lets talk (therapist name)" Patient continues to scream and curse at (therapist) and then starts throwing legos, trash can, and chairs. Patient also "partially" broke the faucet in the dayroom. Patient was asked to calm down and talk, patient refused. Patient was pacing and then went in a corner and started calming down. Patient then started twisting (gender) eyeglasses and broke them. A (psych) tech asked for patient to give all them all the pieces of the glasses, and only one lens was given to (tech). House supervisor and staff took patient to room and had (gender) undress in the shower so could see if (gender) was hiding the lense under clothes. Nothing was found. Patient was calm for a little bit then started getting agitated and angry again. (Gender) was yelling, cursing, and threatened the sitter. Patient was offered an oral ativan (anti-anxiety medication), patient refused, then advised that we would have to give an injection. Patient was taken to seclusion."

An interview with the psychiatric Nurse Practitioner (NP) on 4/24/18 at 9:40 AM revealed when asked about Patient 3's behaviors, "(Patient 3) had been here and returned 24 hours later after cutting up (gender) arms. When (Patient 3) first arrived, we had the patient on a 1:1 observations. Then we took (gender) off it. Then we saw behaviors and again started 1:1's. In hindsight should have had a 1:1 all the time. Has been on a 1:1 since the light bulb incident." "Obviously we don't intervene early, have to think about it. We try to give them their dignity." When asked if the NP worries about the patient's safety here on the BHU, the NP replied, "Everyday, wonder why can the windows open, why we have metal lights, just different environmental issues, but I have confidence in the staff. They do watch the patients, they do 15 minute checks."

Observations noted during the tour of the BHU unit on 4/24/18 [from 8:45 AM until 10:00 AM] revealed:
-The unit has 4 locked pods surrounding the nurses station. It was noted that Patient 3 was asleep on a mattress on the floor in the common area of one pod, a 1:1 staff member was present. Patient 2 was sitting on a mattress on the floor in a 2nd pod, a 1:1 staff member was present. The other 2 pods of the unit were locked with patients present.
-The staffing for BHU consisted of either 2 RN's and a psych tech or 1 RN and 2 psych techs. During the weekday (Monday - Friday) there is a Nurse Practitioner, social worker and 2 therapists. With one person on call during the weekend and evening hours.
-The meal trays were loaded in the cart, they consisted of ceramic dishes, stainless steel silverware, weighted heating slabs for the plates and plastic glasses.
-The patient rooms had scone lights (16 remaining in the BHU rooms), metal paper towel dispensers with an open area where the towels are dispensed that you can insert your hand/wrist/lower arm, and metal toilet paper holders which had the spool removed with the 2 metal sides screwed into the wall.
-The window in the southwest pod that had been kicked open was secured with a metal plate and tamper proof screws.

B. A review of Patient 2's medical record revealed that the patient was admitted under a EPC (Emergency Protective Custody) by local law enforcement to the BHU on 3/28/18 for increasing psychosis and bizarre behaviors. On admission the patient was highly manic (a state of high energy), exhibiting anger, irritability, pressured speech (speech that is accelerated), tangential thought process (thoughts that wanders and lacks focus), delusions of grandeur (believes that one possesses superior qualities) and paranoia (suspicious and mistrustful). The patient was discharged on 4/5/18 to the care of (gender) family.

A review of the facility incident report dated 3/30/18 at 5:10 PM related to Patient 2 revealed:
-Patient 2 had 2-3 episodes of kicking at the window in the commons area. The patient was asked to stop kicking the window after a time. Patient 2 quit kicking the window at that time, but once again kicked the window and would check to see if staff noticed. The patient had stated a few times throughout the shift that (gender) wanted out of the unit and would repel down if necessary. (The BHU is on the 5th floor of the building.) The patient often lost temper and became verbally aggressive towards others, has jumped on the nurses station counter a few times, generally able to be easily redirected. The patient was able to kick the window in the southwest pod open. The patient told staff (gender) wanted fresh air. Initially the staff did not think the patient had exited the window. Review of the security video by the Risk Manager revealed that the patient did in fact, exit and walk out on the ledge for approximately 3 minutes, then reentered the building, and the staff on the unit were not aware this happened. Once staff found the broken window staff also exited the window to look for the patient, who had already re-entered and was in (gender) room.

A review of facility security video for Patient 2 on 3/30/18 revealed:
(The window that the patient broke was a casement window with 2 panes and a metal frame that had a lock in the middle to secure it from opening. This window is used by the window washers to exit through. A rope outside of the window is part of the window washer's equipment.)
-At 4:59 PM the security video showed the patient walking towards the window and kicking the center metal frame 2 times, looking around to see if staff were watching then once again kicked the window center metal frame causing the window to fly open.
-At 5:00 PM, Patient 2 kicked the window open, looked outside the window then shut it again and left the commons area and was seen pacing by the desk.
-At 5:02 PM, Patient 2 returned from (gender) room and pulled a pair of socks from pocket and put them on (gender) hands. Patient 2 then looked around again and opened the window, crawling out on the ledge 5 stories up. The video shows that there was a rope outside of this window, and the video showed Patient 2 "testing" the rope by putting it around (gender) waist and tugging on it. The patient then walked along the ledge out of view.
-At 5:05 PM the patient returns to the window and climbs back in and closes the window and walks back to room.
-At 5:12 PM two staff notice the window moving, they quickly look out the window to look for the patient. The nurse then exits the window to check if the patient is outside. The staff is seen calling security.
-At 5:14 PM the nurse climbs back into the building. Patient 2 then comes out of room.
-At 5:15 PM security arrived, and called facility maintenance to come and re-secure the window. Security remained in front of the window until the window was secured. Patient 2 was taken to seclusion.
THE PATIENT WAS UNSUPERVISED FOR GREATER THAN 12 MINUTES AND WAS OUTSIDE ON THE LEDGE FOR 3 MINUTES AND 18 SECONDS.

An interview with the Risk Manager [on 4/23/18 at 3:10 PM] revealed, "Initially the staff in BHU did not think that (Patient 2) exited the window. But I went to Security to review the video and found that the patient went out the window and was on the ledge for 3 minutes and 18 seconds. That evening we had 55 mph (mile per hour) wind gusts. We found the patient had tied together sheets and blankets in (gender) room. The patient had been telling staff that (gender) was going to escape and wanted out. Was not put on escape precautions."

Review of the nursing progress note dated 3/30/18 at 7:16 PM revealed, that on examination of Patient 2's room, there were multiple blankets tied together.

Review of the Psychiatrist Progress note's for Patient 2 revealed:
- 3/31/18 at 9:40 AM -"Patient seen, I discussed care with staff to include reviewing incident last PM of pt kicking open window with report of patient on ledge "wanting to get fresh air" with multiple blankets tied together in room. Patient placed in seclusion area with continuous pounding of walls, verbal outbursts, receiving multiple PRN's (as needed medications) last PM and this AM. Poor sleep with continued delusional/manic thought process behaviors." Plan included: begin a loading dose of Depakote (mood stabilizer) of 20 mg/kg (milligram per kilogram) to include 500 mg po (by mouth) 4 x (times) daily today and then 1000 mg po bid (twice a day). Continue Zyprexa (antipsychotic medication), continue to reality test patient with least restrictive form of care including locked seclusion based on last 15 hours of patient's behavior and ongoing psychosis/mania - restraint policy in place."
-4/1/18 at 8:30 AM - "Patient seen and evaluated. I discussed care with staff. Patient still highly volatile with mood swings/impulsive behaviors of yelling/ pounding doors/windows with spoor sleep and delusions of "galaxies" and grandiosity." Plan included: Add [prn trazadone (antidepressant), no reality test with patient if banging/hitting walls/doors/windows continue. Will need to be placed in physical restraints for patient's physical safety- did get a shower. May be able to talk with (sibling) today on phone. Check VPL (Valproic Acid Level- check blood to check for Depakote level.)/ CMP (complete metabolic profile)/ CBC (complete blood count) in AM."
-4/1/18 at 12:12 PM - Doctor will allow patient out of seclusion and monitor patient. Patient is appropriate and cooperative.

C. A review of Patient 4's medical record revealed that the patient was admitted under a EPC (Emergency Protective Custody) by local law enforcement to the BHU on 4/14/18 for homicidal threats (threaten to kill someone else) and suicidal threats (threaten to kill themselves). On admission the patient had a persistent mood disorder with history of bipolar affective disorder (a disorder characterized by an elevation or low mood swings) with psychotic features (lost contact with reality); a history of schizo-affective disorder (a disorder that patients experience mood swings and out of touch with reality); benzodiazepine use disorder (over use and dependency of anti anxiety medication) and cannibis use disorder (usage of marijuana).

A review of the facility incident report dated 4/19/18 at 7:56 PM related to Patient 4 revealed:
-At approximately 7:55 PM the patient was very upset and angry. Patient 4 was asked if (gender) would like a pill for anxiety, which Patient 4 responded "Yes", but also would like a pair of sweat pants to wear. The patient then pulled up (gender) shirt which revealed a pair of shorts that contained a tied string around the waist band. When asked where the patient got the pants, Patient 4 responded "Nevermind, you aren't getting these pants." The patient then backed into (gender) room and sat in the corner on the floor. The nurse retrieved the Atarax (anti anxiety) medication to administer. When the nurse returned at 8:06 PM with the medication, Patient 4 lifts the shirt again and the string is was gone. When asked what happened to the string the patient said, "I thought you were calling security and were planning on taking my shorts so I tore the string out and flushed it down the toilet." The nurse then told the patient that a room search would be completed, the patient agreed. The string was not found, so the House Supervisor was notified at 8:10 PM. The House Supervisor informed the nurse that the night before Patient 4 told them how easy it would be to hide stuff in the ceiling panels. The nurse then contacted maintenance to come to and check the ceiling panels in the patient's room, but realized that there were no ceiling panels in patient rooms, so contacted security to review the hallway video to ensure that the patient did not put anything in those panels. The patient was monitored every 15 minutes.

D. A review of Patient 5's medical record revealed that the patient is a 12 year old admitted to the BHU on 4/21/18 from the emergency department following a suicide attempt/suicidal threats and overdose of an unknown medication.

A review of the facility incident report dated 4/22/18 at 7:00 PM related to Patient 5 revealed:
-The patient was found sitting on the bed with hoodie sleeves wrapped around (gender) neck. There were also superficial lacerations to the left inner wrist. Patient 5 was put on "line of vision" (in sight at all times) monitoring due to trying to choke self with hoodie. On 4/24/18 the patient remains on 1:1 line of vision monitoring.

A review of the Psychiatric NP note dated 4/23/18 at 2:00 PM revealed, "Reports being sad about being away from family. Reports poor sleep. Denies suicidal ideation's, but asks for sweatshirt back so can "choke myself to keep myself from crying." Plan to continue medications and therapy. Reports no side effects from medications.

E. A review of the Patient Bill of Rights provided to each patient on admission states, "As a patient at (this hospital name), you have the right to: Nondiscriminatory access to care in a SAFE AND SECURE ENVIRONMENT within the hospital's capability, mission, and applicable laws and regulations. This environment supports the positive self-image of patients and preserves your human dignity."

F. A review of the Policy titled, "Assessment, treatment and reporting of suspected abuse or neglect" last revised on 4/2015 revealed, "Categories of Reportable Abuse and Neglect: Denial of Essential Services: denial of those services necessary to safeguard the person or property to the extent that there is imminent or potential danger of the person suffering physical injury, psychological harm, or exploitation. Such services shall include, but are not limited to, sufficient and appropriate food and clothing, temperate and sanitary shelter, treatment for physical and mental health needs proper supervision, and protection from physical injury, abuse, exploitation, sexual abuse or assault and psychological harm. Examples include, but are not limited to, INADEQUATE SUPERVISION, FAILURE TO INTERVENE TO PREVENT ABUSE BY ANOTHER OR IGNORING NEEDS OF THE INDIVIDUAL."

G. A review of the Policy titled "Utilization of Restraints/Seclusion" last revised 7/2017 revealed, "Seclusion/Restraint/Drug Restraint for Violent, Self-Destructive Behavior: Indications-Attempts to cause physical harm to others such as, but not limited to, hitting, kicking, biting, throwing objects at others, or attempts to harm self such as, but not limited to, cutting self, hitting walls or objects with enough force to injure self, or other behaviors that cause bodily harm."

H. An interview with the Chief Nursing Officer on 4/24/18 at 8:30 AM revealed, "There has been an increase in the BHU patient acuity. There had been a director of that unit that did not work out and currently there is an interim director. They are full staffed, but I feel that the staff are lacking the skill set to manage the patients psychiatric behaviors."

The lack of supervision and the lack of a safe environment in the BHU area was demonstrated from 3/30/18-present by not ensuring visitors were not bringing in items that could pose a danger to the patients such as cigarette lighters; by not intervening quickly to de-escalate a patient when their behaviors are dangerous to themselves or others, such as destroying property, throwing hospital property, not ensuring the 15 minute checks are being completed timely; by not ensuring the environment is safe such as breakable lights, metal paper towel holders, metal toilet paper holders; not intervening timely when patients are running down the hall and kicking at windows; and not ensuring that patients personal items are safe and do not have strings or items that can be used to harm themselves or others.