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Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure that the rights of each patient are protected.

Findings include:

1. The facility failed to ensure that ligature risks are mitigated in environments where patients are at risk for self-harm (Cross refer to Tag A-144).

2. The facility failed to ensure that their policy addressing the safety of patients while on 1:1 observation, is implemented (Cross refer to Tag A-144).

3. The facility failed to ensure that signage informing patients of their rights is prominently displayed in every patient room (Cross refer to Tag A-117).

4. The facility failed to ensure that its policy regarding restraint management, is implemented (Cross refer to Tag A-168 and Tag A-185).

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that its policy and procedure regarding patient rights, is implemented.

Findings include:

Reference: Facility policy, "Informing Patients of their Rights and Responsibilities" states, " ... Signage prominently displayed in every patient room, nursing station and hospital department informs patients/family members of 'Patient Rights' under the State of New Jersey law. ... ."

1. During a tour of the emergency department (ED) on 1/6/20 at 10:54 AM, the following was observed:

a. The Isolation room did not have Patient Rights signage posted in the room.

b. The Psychiatric Emergency Services (PES) room did not have Patient Rights signage posted in the room.

2. During a tour of 3R Medical/Surgical Unit on 1/7/20 at 11:43 AM, the Patient Rights signage posted in Room #362 was not prominently displayed, and was not visible to the patient in Bed #1.

3. During a tour of 2R Medical/Surgical/Telemetry Unit on 1/7/20 at 12:43 PM, the Patient Rights signage posted in Room #269 was not prominently displayed, and was not visible to the patient in Bed #1.

4. Upon interview, Staff #1 confirmed that Patient Rights signage is posted in the same location for all patient rooms on units 2R and 3R. Staff #1 confirmed that the Patient Rights signage is not visible to patients in Bed #1 of these rooms.

5. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above findings.

A. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that ligature risks are mitigated in environments where patients are at risk for self-harm.

Findings include:

Reference #1: Facility Risk Assessment of Behavioral Health Unit dated 3/7/2018 states, "Item: Bathroom Doors; Discussion: Can be used as ligature point; Recommendation: Will be removed and break away curtain will be installed. Mitigation strategy All at risk patient has a 1:1 staff member while deemed a risk. ... Emergency Department... Item: Sinks in bathrooms are a ligature point; Discussion: Sinks would provide a ligature point; Recommendation: Mitigation strategy; at risk patients have a 1:1 staff member while considered a risk... Item: Light fixtures in bathrooms; Discussion: Would present a ligature point; Recommendation: Mitigation strategy; at risk patients have a 1:1 staff member while considered a risk. ... ."

Reference #2: Facility Risk Assessment of Behavioral Health Environment dated October 2018 states, "... 19. Risk Summary, Mitigation Actions Taken... There are 5 medical beds that have ligature points... 15. Risk Summary, Mitigation Actions Taken... Furniture in the day room, lounge and dining room have arms and legs that could be ligature risks. ... 18. Risk Summary, Mitigation Actions Taken... Hallways are not visible on the back of the unit. There are cameras at the desk but the monitoring is not assigned. ... ."

Reference #3: Facility policy, "Management of Psychiatric Patients in the ED" states, "... Patients who present with psychiatric complaints will be interviewed by the triage nurse to determine patient's need for safety... A suicide risk assessment will be completed at triage to determine risk and need for 1:1 observation. ... ."

Reference #4: Facility policy, "Patient Safety Observation" states, "... 1:1 Constant Observation: Within arm's length Patients at the highest levels of risk or harming themselves or others, may need to be nursed in close proximity. ... Bathroom Access and Privacy - Constant Observations... Patients at the highest levels of risk of harming themselves or others may need to have a reduced level of privacy, which must be clearly defined (e.g. bathing, toilet). Note that safety must be balanced against privacy and dignity and a patient on constant observation, proximity within eyesight or arm's length, must remain so at all times. It is essential the clinical team explains this to the patient. ... ."

1. During a tour of the Emergency Department (ED) on 1/6/20 at 10:40 AM, Staff #4 identified the isolation (ISO) room and the psychiatric emergency services (PES) room as rooms where psychiatric patients, including suicidal patients, are placed while being evaluated. In the ISO Room, the following was observed:

a. Plastic bags in the trash can and in the biohazard trash can

b. The bathroom located in the ISO room contained ligature points in the following areas: under the sink, three (3) grab bars, and the toilet

c. The paper towel dispenser and the toilet paper dispenser could be removed from the wall and used as a weapon

d. Removable screws that were not safety screws were observed on the floor air handling unit

2. Upon interview, Staff #4 confirmed that psychiatric patients, including suicidal patients, placed in the PES room utilize the hallway bathroom. In the hallway patient bathroom, the following was observed:

a. A plastic bag in the trash can

b. A glass mirror over the sink

c. The bathroom contained ligature points in the following areas: under the sink, the toilet, and two (2) grab bars

d. The paper towel dispenser and the toilet paper dispenser can be removed from the wall and used as a weapon

3. Upon interview, Staff #3 indicated that the ligature risks identified in the ISO room bathroom and the hallway patient bathroom were mitigated by ensuring suicidal patients were placed on 1:1 (one-to-one) observation. Staff #3 stated that ED staff performing 1:1 observation were required to physically enter the bathroom with patients and "maintain an arm's length distance" from them.

a. Upon interview at 10:45 AM, Staff #5 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #5 stated that when he/she performs 1:1 observation on a suicidal patient, and accompanies them to the bathroom, he/she enters the bathroom with the patient. Staff #5 stated, "This is new. We used to stand outside the door to give patients privacy but that changed a couple of months ago. Now we go in."

b. Upon interview at 11:22 AM, Staff #9 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #9 was asked what he/she would do if he/she was performing a 1:1 observation on a patient of the opposite sex, and the patient needed to use the bathroom. Staff #9 stated that he/she would not go into the bathroom with the patient, but would "stand in the doorway." Staff #9 asked if he/she could maintain an arm's length distance from the patient by standing in the doorway. He/she stated, "No."

4. During a tour of the Inpatient Psychiatric Unit on 1/6/2020 at 11:45 AM, the following was observed:

a. Room #513 contained two (2) medical beds. Staff #12 confirmed that the medical beds remained in the room at all times. Staff #12 confirmed that patients without an order, or a documented need for a medical bed, were placed in a medical bed if they were assigned to Room #513.

b. Room #508 contained one (1) medical bed. The medical bed had a black electric cord that was long enough to present a ligature risk.

c. A whiteboard and bulletin board located in the dining room were mounted with screws that were not safety screws.

d. In the television (TV) Lounge, there was a gap between the whiteboard and the wall, presenting a ligature point.

(i) In the TV Lounge, the whiteboard and a wall mounted clock could be easily removed and used as a weapon.

e. In the TV Lounge and Group Therapy Room, a casing surrounding the televisions were observed with gaps between the wall and the TV casing on the right and left top corners. The gaps created two (2) ligature points on each TV casing.

(i) Upon interview, Staff #10 stated that the casing is designed to prevent a patient from pulling the TV off the wall to use as a weapon. Staff #10 confirmed that the gaps were a ligature point.

f. In Room #508, a box of gloves was present on a shelf. Room 508 was unlocked, unsecured, and easily accessible to all patients.

g. The shower head in Room #508 and Room #513 contained a gap between the wall and the fixture that could present a ligature risk.

h. The bathroom window in Room #508 contained two shade hooks at the top of the window. These hooks presented ligature points.

i. A metal support track, located at each window and shower stall and used to hang window and shower curtains, contained a "notch" that could present a ligature risk. Staff #11 confirmed that the metal support track was present in all patient rooms and bathrooms.

j. The following areas contained chairs that had arm loops that could present a ligature risk: thirteen (13) chairs in the dining room, ten (10) chairs in the TV Lounge, and fifteen (15) chairs in the Conference Room.

k. The bathroom door in Room #513 was identified in the Facility's Risk Assessment as being a ligature risk. The Risk Assessment indicated that the bathroom doors in the unit would be removed. The bathroom door in Room #513 was still present.

l. Upon interview on 1/6/2020 at 11:50 AM, Staff #12 confirmed that on 7/3/19, a patient housed on the Inpatient Psychiatric Unit was successful in committing suicide via hanging in the bathroom of Room #513. Staff #12 stated that "at this time we believe that the patient tied his/her gown around the bathroom door and did it that way."

5. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above findings.

6. On 1/6/2020, Staff #2 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:15 PM. An acceptable IJ removal plan was received from the facility on 1/7/2020. On 1/16/2020, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: a tour of the ED and Inpatient Psychiatric Unit, review of staff education and monitoring audits, staff interviews, and review of revised policies and procedures. The facility was determined to be in compliance with the IJ removal plan and the IJ was removed.


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B. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that their policies and procedures regarding observation levels for at risk patients, are implemented.

Findings include:

Reference #1: Facility policy, "Patient Safety Observation" states, " ... C. Procedure ... Observation levels... 1:1 Constant Observation: Within arm's length Patients at highest levels of risk or harming themselves or others, may need to be nursed in close proximity. ... Medical Professional Role and Responsibility for 1:1 Observation... The patients will be assisted to the bathroom, leaving the door open... Note that safety must be balanced against privacy and dignity and a patient on constant observation, proximity within eyesight or arm's length, must remain so at all times. ... ."

Reference #2: Facility policy, "Observation Levels" states, " ... Definitions... One to One (1:1): Consists of one to one staff observation with a patient never farther away than arm's length. The patient remains within arm's length of a staff member at all times. ... Procedure... L. One to One: 1. The patient is assigned a constant one to one staff member at arm's length from the patient. ... ."

1. During a tour of the Emergency Department (ED) on 1/6/2020 at 10:40 AM, the following was observed:

a. Upon interview, Staff #3 indicated that the ligature risks identified in the ISO room bathroom and the hallway patient bathroom were mitigated by ensuring suicidal patients were placed on 1:1 (one-to-one) observation. Staff #3 stated that ED staff performing 1:1 observation were required to physically enter the bathroom with patients and "maintain an arm's length distance" from them.

b. Upon interview at 10:45 AM, Staff #5 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #5 stated that when he/she performs 1:1 observation on a suicidal patient, and accompanies them to the bathroom, he/she enters the bathroom with the patient. Staff #5 stated, "This is new. We used to stand outside the door to give patients privacy but that changed a couple of months ago. Now we go in."

c. Upon interview at 11:18 AM, Staff #22 was asked how he/she would assist a patient on 1:1 observation to the bathroom. Staff #22 stated that he/she would accompany the patient to the bathroom. He/she stated that "if the patient was not suicidal, he/she would give the patient the benefit of the doubt and remain outside of the bathroom with the door closed while the patient was inside, to provide some privacy."

d. Upon interview at 11:22 AM, Staff #9 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #9 was asked what he/she would do if he/she was performing a 1:1 observation on a patient of the opposite sex, and the patient needed to use the bathroom. Staff #9 stated that he/she would not go into the bathroom with the patient, but would "stand in the doorway." Staff #9 asked if he/she could maintain an arm's length distance from the patient by standing in the doorway. He/she stated, "No."

2. During a tour of the Inpatient Psychiatric Unit on 1/6/2020 at 12:13 PM, Staff #23 was questioned how he/she would assist a patient on 1:1 observation to the bathroom. Staff #23 stated that he/she would remain in the doorway of the bathroom while the patient was using the bathroom.

a. Upon interview at 12:20 PM, Staff #12 confirmed that staff are required to enter the bathroom with patients that are on 1:1 observation.

3. During a tour of 2R Medical-Surgical/Telemetry Unit on 1/7/2020 at 11:15 AM, the following was revealed:

a. In Room #275, Patient #9 was under 1:1 observation for suicidal ideation. He/she was transferred from the Inpatient Psychiatric Unit on 1/6/2020 at 3:30 PM with complaints of shortness of breath and elevated troponin levels.

b. Staff #20 was the staff member performing the 1:1 observation for Patient #9. Upon interview at 11:23 AM, Staff #20 was questioned how he/she would assist Patient #9 if he/she needed to use the bathroom. Staff #20 stated, "If (he/she) goes to the bathroom, I stand outside and crack the door to give (him/her) privacy and make sure the patient is not harming (him/herself). But I don't go in. I stand outside."

4. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above findings.

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that restraints are applied in accordance with a physician's order.

Findings include:

Reference: Facility policy, "Restraints: Patient Safety/Behavioral/Seclusion" states, " ... Medical/Surgical Management - The physician shall immediately be summoned and requested to issue an order and perform an immediate face to face. Documentation... Each episode of use is recorded. Documentation includes... Written orders for use ... ."

1. Review of Medical Record #7 on 1/7/2020 revealed the following:

a. On 11/26/19 at 1:39 AM, a nursing assessment of restraints was documented in the medical record. The nursing assessment indicated that bilateral soft wrist restraints were applied to the patient "for safety."

(i) There was no evidence in the medical record of a physician's order for restraints on 11/26/19.

(ii) There was no evidence in the medical record that a face-to-face assessment was performed by the physician on 11/26/19.

2. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above findings.

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that restraint documentation is completed in accordance with facility policy and procedure.

Findings include:

Reference: Facility policy, "Restraints: Patient Safety/Behavioral/Seclusion" states, " ... Documentation... Each episode of use is recorded. Documentation includes... Complete monitoring flow sheet... ."

1. Review of Medical Record #7 on 1/7/2020 revealed the following:

a. On the "Medical (Non-Violent) Restraint Management Daily Flow Sheet" dated 12/5/19, the following sections were not completed:

(i) "4. Type of Restraint:"

(ii) "5. Education of Patient/Family:"

(iii) "6. Reassessment completed for continued restraint usage:"

(iv) "7. Restraints discontinued:"

(v) "8. Reason for discontinuation:"

2. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above finding.

Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that nurse staffing levels are maintained in accordance with the facility's established staffing matrix.

Findings include:

1. Review of the staffing worksheet for 2R Medical-Surgical/Telemetry Unit on 1/7/2020 revealed staffing shortages on the following dates and times:

a. For the night shift, 7 PM - 7 AM, on 1/6/2020, the unit census was thirty-two (32). The staffing matrix called for seven (7) RNs (Registered Nurses) and three (3) CNAs (Certified Nursing Assistants). The staffing worksheet revealed that six (6) RNs and three (3) CNAs were present during the shift. The unit was short staffed one (1) RN from 7 PM - 7 AM.

b. For the day shift, 7 AM - 7 PM, on 1/7/2020, the unit census was thirty (30). The staffing matrix called for eight (8) RNs and three (3) CNAs. The staffing worksheet revealed that seven (7) RNs and three (3) CNAs were present during the shift. The unit was short staffed one (1) RN from 7 AM - 7 PM.

2. Review of the staffing worksheet for 3R Medical-Surgical Unit on 1/7/2020 revealed staffing shortages on the following dates and times:

a. For the day shift, 7 AM - 7 PM, on 1/6/2020, the unit census was twenty-three (23). The staffing matrix called for five (5) RNs and three (3) CNAs. The staffing worksheet revealed that four (4) RNs and four (4) CNAs were present during the shift. The unit was short staffed one (1) RN from 7 AM - 7 PM.

b. For the night shift, 7 PM - 7 AM, on 1/6/20, the unit census was twenty-eight (28). The staffing matrix called for five (5) RNs and three (3) CNAs. The staffing worksheet revealed that five (5) RNs and two (2) CNAs were present during the shift. The unit was short staffed one (1) CNA from 7 PM - 7 AM.

c. For the day shift, 7 AM - 7 PM, on 1/7/20, the unit census was twenty-six (26). The staffing matrix called for six (6) RNs and three (3) CNAs. The staffing worksheet revealed that five (5) RNs and three (3) CNAs were present during the shift. The unit was short staffed one (1) RN from 7 AM - 7 PM.

3. Review of the staffing worksheet for the ICU/CCU (Intensive Care Unit) on 1/7/20 revealed staffing shortages on the following dates and times:

a. For the day shift, 7 AM - 7 PM, on 1/6/20, the unit census was thirteen (13). The staffing matrix called for six (6) RNs and two (2) CNAs. The staffing worksheet revealed that five (5) RNs and one (1) CNA were present during the shift. The unit was short staffed one (1) RN and one (1) CNA from 7 AM - 7 PM.

b. For the day shift, 7 AM - 7 PM, on 1/7/20, the unit census was twelve (12). The staffing matrix called for six (6) RNs and one (1) CNA. The staffing worksheet revealed that five (5) RNs and one (1) CNA were present during the shift. The unit was short staffed one (1) RN from 7 AM - 7 PM.

4. Staff #1 confirmed the above findings.

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that an environment that ensures the safety of patients, is maintained.

Findings include:

1. The facility failed to ensure that ligature risks are mitigated in environments where patients are at risk for self-harm (Cross refer to Tag A-701).

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that ligature risks are mitigated in environments where patients are at risk for self-harm.

Findings include:

Reference #1: Facility Risk Assessment of Behavioral Health Unit dated 3/7/2018 states, "Item: Bathroom Doors; Discussion: Can be used as ligature point; Recommendation: Will be removed and break away curtain will be installed. Mitigation strategy All at risk patient has a 1:1 staff member while deemed a risk. ... Emergency Department... Item: Sinks in bathrooms are a ligature point; Discussion: Sinks would provide a ligature point; Recommendation: Mitigation strategy; at risk patients have a 1:1 staff member while considered a risk... Item: Light fixtures in bathrooms; Discussion: Would present a ligature point; Recommendation: Mitigation strategy; at risk patients have a 1:1 staff member while considered a risk. ... ."

Reference #2: Facility Risk Assessment of Behavioral Health Environment dated October 2018 states, "... 19. Risk Summary, Mitigation Actions Taken... There are 5 medical beds that have ligature points... 15. Risk Summary, Mitigation Actions Taken... Furniture in the day room, lounge and dining room have arms and legs that could be ligature risks. ... 18. Risk Summary, Mitigation Actions Taken... Hallways are not visible on the back of the unit. There are cameras at the desk but the monitoring is not assigned. ... ."

Reference #3: Facility policy, "Management of Psychiatric Patients in the ED" states, "... Patients who present with psychiatric complaints will be interviewed by the triage nurse to determine patient's need for safety... A suicide risk assessment will be completed at triage to determine risk and need for 1:1 observation. ... ."

Reference #4: Facility policy, "Patient Safety Observation" states, "... 1:1 Constant Observation: Within arm's length Patients at the highest levels of risk or harming themselves or others, may need to be nursed in close proximity. ... Bathroom Access and Privacy - Constant Observations... Patients at the highest levels of risk of harming themselves or others may need to have a reduced level of privacy, which must be clearly defined (e.g. bathing, toilet). Note that safety must be balanced against privacy and dignity and a patient on constant observation, proximity within eyesight or arm's length, must remain so at all times. It is essential the clinical team explains this to the patient. ... ."

1. During a tour of the Emergency Department (ED) on 1/6/2020 at 10:40 AM, Staff #4 identified the isolation (ISO) room and the psychiatric emergency services (PES) room as rooms where psychiatric patients, including suicidal patients, are placed while being evaluated. In the ISO Room, the following was observed:

a. Plastic bags in the trash can and in the biohazard trash can

b. The bathroom located in the ISO room contained ligature points in the following areas: under the sink, three (3) grab bars, and the toilet

c. The paper towel dispenser and the toilet paper dispenser could be removed from the wall and used as a weapon

d. Removable screws that were not safety screws were observed on the floor air handling unit

2. Upon interview, Staff #4 confirmed that psychiatric patients, including suicidal patients, placed in the PES room utilize the hallway bathroom. In the hallway patient bathroom, the following was observed:

a. A plastic bag in the trash can

b. A glass mirror over the sink

c. The bathroom contained ligature points in the following areas: under the sink, the toilet, and two (2) grab bars

d. The paper towel dispenser and the toilet paper dispenser can be removed from the wall and used as a weapon

3. Upon interview, Staff #3 indicated that the ligature risks identified in the ISO room bathroom and the hallway patient bathroom were mitigated by ensuring suicidal patients were placed on 1:1 (one-to-one) observation. Staff #3 stated that ED staff performing 1:1 observation were required to physically enter the bathroom with patients and "maintain an arm's length distance" from them.

a. Upon interview at 10:45 AM, Staff #5 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #5 stated that when he/she performs 1:1 observation on a suicidal patient, and accompanies them to the bathroom, he/she enters the bathroom with the patient. Staff #5 stated, "This is new. We used to stand outside the door to give patients privacy but that changed a couple of months ago. Now we go in."

b. Upon interview at 11:22 AM, Staff #9 identified him/herself as a staff member whose duties included performing 1:1 observations. Staff #9 was asked what he/she would do if he/she was performing a 1:1 observation on a patient of the opposite sex, and the patient needed to use the bathroom. Staff #9 stated that he/she would not go into the bathroom with the patient, but would "stand in the doorway." Staff #9 asked if he/she could maintain an arm's length distance from the patient by standing in the doorway. He/she stated, "No."

4. During a tour of the Inpatient Psychiatric Unit on 1/6/20 at 11:45 AM, the following was observed:

a. Room 513 contained two (2) medical beds. Staff #12 confirmed that the medical beds remained in the room at all times. Staff #12 confirmed that patients without an order, or a documented need for a medical bed, were placed in a medical bed if they were assigned to Room 513.

b. Room 508 contained one (1) medical bed. The medical bed had a black electric cord that was long enough to present a ligature risk.

c. A whiteboard and bulletin board located in the dining room were mounted with screws that were not safety screws.

d. In the television (TV) Lounge, there was a gap between the whiteboard and the wall, presenting a ligature point.

(i) In the TV Lounge, the whiteboard and a wall mounted clock could be easily removed and used as a weapon.

e. In the TV Lounge and Group Therapy Room, a casing surrounding the televisions were observed with gaps between the wall and the TV casing on the right and left top corners. The gaps created two (2) ligature points on each TV casing.

(i) Upon interview, Staff #10 stated that the casing is designed to prevent a patient from pulling the TV off the wall to use as a weapon. Staff #10 confirmed that the gaps were a ligature point.

f. In Room 508, a box of gloves was present on a shelf. Room 508 was unlocked, unsecured, and easily accessible to all patients.

g. The shower head in Room 508 and Room 513 contained a gap between the wall and the fixture that could present a ligature risk.

h. The bathroom window in Room 508 contained two shade hooks at the top of the window. These hooks presented ligature points.

i. A metal support track, located at each window and shower stall and used to hang window and shower curtains, contained a "notch" that could present a ligature risk. Staff #11 confirmed that the metal support track was present in all patient rooms and bathrooms.

j. The following areas contained chairs that had arm loops that could present a ligature risk: thirteen (13) chairs in the dining room, ten (10) chairs in the TV Lounge, and fifteen (15) chairs in the Conference Room.

k. The bathroom door in Room 513 was identified in the Facility's Risk Assessment as being a ligature risk. The Risk Assessment indicated that the bathroom doors in the unit would be removed. The bathroom door in Room 513 was still present.

l. Upon interview on 1/6/20 at 11:50 AM, Staff #12 confirmed that on July 3, 2019, a patient housed on the Inpatient Psychiatric Unit was successful in committing suicide via hanging in the bathroom of Room 513. Staff #12 stated that "at this time we believe that the patient tied his/her gown around the bathroom door and did it that way."

5. Staff #1, Staff #2, Staff #3 and Staff #13 confirmed the above findings.

6. On 1/6/2020, Staff #2 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:15 PM. An acceptable IJ removal plan was received from the facility on 1/7/2020. On 1/16/2020, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: a tour of the ED and Inpatient Psychiatric Unit, review of staff education and monitoring audits, staff interviews, and review of revised policies and procedures. The facility was determined to be in compliance with the IJ removal plan and the IJ was removed.