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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient Rights was out of compliance.

A-0144 The Patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which posed a safety risk to patients or others, were not accessible to patients in three of three inpatient psychiatric units observed.

Based on observations, interviews, and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which posed a safety risk to patients or others, were not accessible to patients in three of three inpatient psychiatric units observed.

Findings include:

Facility policy:

According to the policy, Contraband, to ensure patient safety, the facility must identify and prevent dangerous items (contraband) from entering into the therapeutic environment. Certain items are unsafe on the units and are considered contraband. As the safety and security of our patients are paramount to all other concerns, we have developed a list of contraband items not allowed on the units to prevent patients from injuring themselves or others.

Contraband: Term used to describe prohibited or unauthorized items. Certain items are clearly considered contraband in the hospital environment. Any item that poses a safety risk may be considered contraband or if an item poses safety risk or interferes with the rights of others.

The policy listed items, including, but not limited to, office supplies associated with danger risk such as pencils longer than five inches.

When any staff member notices an item that could be considered contraband, they will take immediate action to address any related safety issues. Promptly notify patients and address issues as soon as possible. Complete an incident report for the nurse supervisor's review, prior to the end of the shift.

1. The facility failed to ensure pencils were not accessible to patients in the inpatient psychiatric units.

A. Observations conducted of inpatient psychiatric units on 6/29/23 revealed pencils were accessible to unsupervised patients.

i. Observations conducted on 6/29/23 at 4:00 p.m. of the adolescent unit Discovery revealed a colored pencil in a board game box in a group therapy room. During the observation, behavioral health assistant (BHA) #1, who was assigned to provide care on the unit, stated she was unaware the pencil was in the board game box. When asked why it was important to remove the pencil from the box BHA #1 stated pencils were considered contraband and could be used to self-harm or harm others.

a. Document review of the facility's self-harm patient list revealed five patients on the Discovery unit were at risk for self-harm.

ii. Observations conducted on 6/29/23 at 4:18 p.m. of the adult unit Compass revealed an unsecured container on a shelf in the group room which contained one colored pencil and three small pencils. The group room had patients present without staff supervision during the observation.

iii. Observations conducted on 6/29/23 at 4:29 p.m. of the adult unit Compass revealed a pencil in patient room 2069 on a shelf.

iv. Observations conducted on 6/29/23 at 4:32 p.m. of the adult unit Horizon revealed a pencil on the table of a group therapy room. The group room had patients present without staff supervision during the observation.

a. Document review of the facility's self-harm patient list revealed three patients on the Horizon unit were at risk for self-harm.

The above observations were in contrast to the Contraband policy which read any item that posed a safety risk may be considered contraband, or if an item posed a safety risk or interfered with the rights of others it would be turned over to staff to dispose of. In addition, the policy listed items including, but not limited to, office supplies associated with danger risk such as pencils longer than five inches.

B. Interviews with staff revealed the facility failed to ensure the safety of patients from potential contraband items on the inpatient units.

i. On 6/29/23 at 4:07 p.m., BHA #1 was interviewed. BHA #1 stated pencils were kept at the nurse's station of the adolescent unit Discovery. BHA #1 further stated pencils were signed in and out, and were counted all day long. BHA #1 explained patients were expected to be watched at all times when using pencils. BHA #1 stated if a pencil went missing, staff would check patients for the missing pencil. BHA #1 stated patients could hurt themselves or others as pencils were sharp objects. BHA #1 stated pencils were expected to be counted before patients left the group room to make sure none were missing.

ii. On 6/29/23 at 4:22 p.m., an interview with BHA #2 was conducted. BHA #2 stated pencils and colored pencils were left in common areas of the Compass unit for use. BHA #2 said pencils were only removed from the area when there were patients around with self-harm risk. BHA #2 stated the adult unit was given more leeway than the adolescent unit with the use of pencils. BHA #2 said if while doing patient rounds they found a patient self-harming they would remove all pencils from the unit.

This was in contrast to the Contraband policy which read any item that posed a safety risk may be considered contraband or if an item poses a safety risk or interferes with the rights of others it would be turned over to staff to dispose of.

iii. On 6/29/23 at 4:35 p.m., an interview with BHA #4 was conducted. BHA #4 said patients could use pencils in the group room but they were taken back and counted when patients were done with them. BHA #4 said patients could not go back to their rooms with pencils because they could be used to self-harm.

iv. On 7/5/23 at 11:15 a.m., BHA #5 was interviewed. BHA #5 explained self-harm was defined as self-inflicting pain either physically or psychologically. BHA #5 stated contraband was defined as anything with laces, strings, sharp edges, food in the room, or anything the staff did not provide. BHA #5 said every shift staff checked for any objects which could have been used to self-harm and there was a sheet used to document these things. BHA #5 stated the staff member who brought out pencils was responsible for collecting pencils when patients were finished using them. BHA #5 stated if a pencil was missing, staff were expected to speak to patients and search rooms. BHA #5 said pencils of any size could be used as a weapon to self-harm.

v. On 7/5/23 at 2:55 p.m., an interview with registered nurse (RN) #7 was conducted. RN #7 stated the size of the pencil did not matter and as long as the pencil had a pointy end it could be used to self-harm or harm others.

vi. On 6/29/23 at 4:29 p.m., an interview with chief nursing officer (CNO) #3 was conducted. CNO #3 stated patients should not have pencils in their rooms. CNO #3 further explained patients could have used pencils for self-harm or to harm others.

vii. On 6/29/23 at 5:33 p.m., the director of risk management (DRM) #8 was interviewed. DRM #8 stated she did not have an answer for how the facility determined pencils greater than five inches were a risk for self-harm in the Contraband policy. DRM #8 stated she did not know why five inches made a difference in the ability to self-harm or harm others. DRM #8 said patients were not allowed to have pencils of any length at their disposal and were only allowed to use pencils when directly monitored by staff. DRM #8 said patients should never have pencils of any size in their rooms because it increased the risk of self-harm.

The interviews were in contrast with the observations conducted of the inpatient units, which revealed several pencils unaccounted for and available to unsupervised patients.