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Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting for a patient at high risk for suicide, by having a patient safety attendant inside the room to intervene as ordered and required by policy. (A-144)

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #1) reviewed for complaints/grievances, the Hospital failed to ensure the process for resolution of patient complaint/grievances was followed.

Findings include:

1. The Hospital's policy titled, "Complaint and Grievance Policy" (revised 10/20/2021), was reviewed and required, "...When a patient or patient representative express dissatisfaction, the associates present are to immediately attempt to mitigate the issue(s), and the complaint is to be entered into the appropriate Online Event Database as soon as practical thereafter... Complaints and grievances will be entered into the appropriate Online Event database. The Patient Relations designee for each site will maintain the Online Event database and update the responsible manager in a timely manner to ensure efficient and timely follow-up and resolution..."

2. On 10/25/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought into the Hospital's Emergency Department (ED) on 08/24/2022 at 9:51 PM, with chief complaint of psychiatric evaluation. The record included:
- The behavioral health services intake form assessment note by Intake Clinician (E#8) dated 08/25/2022 at 12:30 AM, included, "Disposition Text: Consulted with [Name of Psychiatrist - MD #2] who rec. [recommended] deflection with outpt. [out-patient] referrals. ED Dr. [ER Physician Assistant - E #3] in agreement as was pt. [Pt. #1]. Wife was not happy with rec. [recommendation] and left ED before BHS [behavioral health services] could give her or pt."
- The BHS [Behavioral Health Services] Admission Assessment by Intake Supervisor (E #6) dated 08/25/2022 at 10:53 AM, included, "Reassessment Note: Pt. [Pt. #1] was assessed on 08/25/2022 in the morning while in ER ...Pt's wife brought Pt. [Pt. #1] back due to "I can't handle him at home." Pt. [Pt. #1] stated he just want to pursue his music career, and everyone is stopping him... Writer consulted with the on-call doctor [Name of the Psychiatrist - MD #3] who recommended deflection ...wife called [Pt. #1's] mother on the phone ...the mother called the writer [profanity word] for not admitting pt. [Pt. #1]..."

3. On 10/26/2022 the Hospital's ED Complaint/Grievance log from 06/01/2022 to 10/25/2022 was reviewed. The log did not include any incident, occurrences, complaints, or grievance related to Pt. #1.

4. On 10/25/2022 at 9:45 AM, the Executive Assistant (E #1) was interviewed. E #1 stated that she vaguely remembers receiving a call from the wife of the patient (Pt. #1) once. E #1 stated that the wife stated they had to wait for a long time in the waiting area, nobody came back to check on the patient (Pt. #1). E #1 stated that the wife continued to say that patient (Pt. #1) was discharged from the hospital and his (Pt. #1's) condition became progressively worse and had to call police. E #1 stated that she (Pt. #1's wife) did not want the hospital to bill the insurance because she (Pt. #1's wife) felt that they had not treated him correctly and the condition would not have been escalated. E #1 stated that she faintly remembers calling the patient advocate and spoke verbally regarding the concern and nothing was officially documented in the complaints or grievance log.

5. On 10/25/20222 at 12:05 PM, the Director of Hospital Relations (E #4) was interviewed. E #4 stated that she does not have any complaints, occurrences, or grievances related to Pt. #1. E #4 stated that she does not recall talking with the Executive Assistant regarding the telephone conversation from Pt. #1's wife.

Based on document review, observation, and interview, it was determined that for 1 of 1 patient (Pt. #2) reviewed at high risk for suicide, the Hospital failed to ensure care in a safe setting by having a patient safety attendant inside the room with the patient to intervene as ordered and required by policy.

Findings include:

1. The Hospital's policy titled, "Patient Safety Attendant (PSA) and Remote Companions" (revised 4/19/2022), was reviewed on 10/26/2022 and required, "Indicators for Initiation of Constant Observation (1:1) Status by a PSA for risk of self-harm or harm to others may include (1) or more of the following: ... 1. Order from a Licensed Independent Practitioner. 2. Verbalization of suicidal thoughts with a plan and intent to follow through... 3. All Patients identified by the Columbia Suicide Severity Rating Scale (CSSRS) as High Risk for Suicide Ideation... Constant Observation (1:1) - means one to one (1:1) observing the patient 24 hours a day... Constant Observation is performed by a PSA inside the room in immediate proximity with continuous visual observation to immediately intervene... The PSA must directly observe the patient at all times..."

2. An observational tour of the Emergency Department (ED) Behavioral Health Pod was conducted on 10/25/2022, between approximately 10:18 AM and 10:45 AM, with the ED Manager (E #5) present. The pod was staffed with 1 Registered Nurse (E #9) and 1 Patient Care Technician (E #10) and consisted of 4 private patient rooms, 2 on each side of the nurses station. Per the Nurse (E#9), there was one patient (Pt. #2) on high suicide risk precautions. Pt. #2 was noted to be in room #3. Pt. #2 was lying on an ED cart in the room with a bed sheet covering her body up to her chest. There was no staff present in the room with Pt. #2. Both E #9 and E #10 were sitting at the nurse's station desk. E #10 did not maintain constant visual observation of the patient during the tour. E #10 at one point left the nurses station to check on the other 2 patients (Pts. #3 and #4) who were roomed on the other side of the pod.

3. The clinical record of Pt. #2 was reviewed with E #9 during the tour at approximately 10:34 AM. Pt. #2 presented to the Hospital's ED on 10/24/2022, at approximately 8:31 PM, for a behavioral health evaluation due to anxiety, suicidal ideation, and self-mutilation. The record included the following:
- A Nurse's Note, dated 10/24/2022 at 8:32 PM, included, "Pt stated she's been hearing voices today telling her to kill herself ... Patient stated she has a history of cutting herself and recently has had an episode of cutting herself this past week ...Suicide Risk Level [CSSRS]: HIGH RISK ..."
- A Physician Report, dated 10/24/2022 at 8:46 PM, included " ...Patient was evaluated by behavioral health and deemed need for inpatient admission due to suicidal ideation with plan and hallucinations ..."
- Orders were placed on 10/24/2022 at 9:21 PM to initiate "Suicide Precautions" and "Sitter at Bedside" and the orders were still active at the time of the tour.

4. An interview was conducted with the ED Manager (E #5) on 10/25/2022, at approximately 1:55 PM. E #5 stated that Pt. #2 should have had a sitter present at the bedside as ordered.

5. An interview was conducted with the Registered Nurse (E #9) on 10/26/2022, at approximately 11:28 AM. E #9 stated that patients who are at high risk for suicide are placed on 1:1 monitoring. E #9 stated that this means that the assigned sitter should have direct view of the patient without distractions. E #9 stated that E #10 was the assigned sitter for Pt. #2 and should ideally have had complete focus on the patient.

6. An interview was conducted with the Patient Care Technician (E #10) on 10/26/2022, at approximately 12:15 PM. E#10 stated that Pt. #2 had an order to have a sitter at the bedside. E #10 stated that the sitter should usually be within arm's length of the patient, in the room by the bed. E #10 stated that E #10 was watching all 3 patients and stated, "They should've only had me watch [Pt. #2] who was high risk. I was sitting closer to the high risk patient by the nursing station." E #10 stated that there was a staffing issue and they "couldn't get another sitter or PCT."

Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#9 and E#10) observed working with behavioral health patients in the ED, the Hospital failed to ensure that staff had up-to-date CPI (Crisis Prevention Intervention) training as required.

Findings include:

1. The Hospital's policy titled, "General - Security Plan" (revised 4/14/2020), was reviewed on 10/31/2022 and required, "...Training: All BHS [Behavioral Health Services] patient care staff are trained in Crisis Prevention Intervention. This training involves verbal and physical de-escalation techniques and the skill of physical restraint, containment, and control of situation. This class must be completed in order to work on a behavioral health floor. Review/revalidation of competence in this area is required every year..."

2. An observational tour of the Emergency Department (ED) Behavioral Health Pod was conducted on 10/25/2022, between approximately 10:18 AM and 10:45 AM, with the ED Manager (E#5) present. The pod was staffed with 1 Registered Nurse (E#9) and 1 Patient Care Technician (E#10). There were 3 behavioral health patients present in the pod during the tour.

3. The personnel files for E#9 and E#10 were reviewed on 10/27/2022 and 10/31/2022 and indicated that E#9's CPI card had expired on 8/20/2022 and E#10's CPI had expired on 6/22/2021.

4. An interview was conducted with the Director of ED and Intensive Care (E#7) on 10/27/2022, at approximately 2:51 PM. E#7 stated that CPI training is a requirement for all staff working in the ED. E#7 stated that this includes float staff such as E#10.

5. An interview with the Director of Human Resources (E#17) on 10/31/2022, at approximately 10:30 AM. E#17 stated that the expectation is for all staff working in the Behavioral Health and ED areas to have current CPI training.