HospitalInspections.org

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to the findings cited at Tag A263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement.

3. Refer to findings cited at Tag A700 under CFR 482.41 - CoP: Physical Environment.

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that:
* The hospital failed to ensure each patient's right to freedom from all forms of abuse and neglect.
* The hospital failed to ensure hospital staff involved in restraint/seclusion were trained and had demonstrated competency in the use of first aid techniques that may be needed during patient restraint and seclusion.
* The hospital failed to ensure each patient's right to receive care in a safe setting. Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to hang themselves and died. Refer to Tag A000 at the beginning of this SOD report for IJ identification, notification, removal plans approval, and verification of removal.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A144 under this CoP, CFR 482.13(c)(2) - Standard: Care in a Safe Setting. Those findings reflect the hospital's failure to ensure Patient 13's right to receive care in a safe setting and represented an IJ situation.

2. Refer to the findings cited at Tag A145 under this CoP, CFR 482.13(c)(3) - Standard: Freedom from Abuse.

3. Refer to the findings cited at Tag A206 under this CoP, CFR 482.13(f)(2)(vii) - Standard: Restraint or seclusion: Staff Training Requirements.

4. Refer to the findings cited at Tag A701, CFR 482.41(a) - Standard: Buildings.

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure each patient's right to receive care in a safe setting in the following areas:

* Failure to develop and implement clearly written, consistent and effective policies and procedures that ensured patients on the inpatient BHU at risk for suicide or self harm were appropriately assessed, monitored and prevented access to unsafe items in the physical environment. Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to hang themselves and died. Those conditions resulted in actual harm for Patient 13 and potential harm to other patients. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

* Failure to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items and areas. Risks had not been identified and/or mitigated and created the opportunity for self-harm. Those included but were not limited to gaps inside closets, holes in underside of bathroom sinks, entry doors to patient rooms, and patient bathroom door (hinges). Those conditions resulted in actual harm for Patient 13 and risk for serious injury or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

* Failure to ensure staff responses to patient incidents included timely, clear and complete investigations to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patients and others. Incidents include but are not limited to failure to prevent patients from accessing unsafe items and self harming, suicidal patients from placing a sheet or blanket around their neck, patient altercations, falls, inappropriate touching between patients, and reported neglect related to incontinence.

Findings include:

1. During interview on 11/28/2023 beginning at 1335 the PNM confirmed that on 11/17/2023 a patient admitted to the inpatient BHU tied a knot in a bed sheet, put the sheet over the door between their room and hallway, closed the door and used the sheet to commit suicide by asphyxiation.

2. Incident documentation for Patient 13 reviewed included that on 11/17/2023 at 1520 "Pt [was] found down with sheet found around [their] neck and not responsive. Code blue initiated and unsuccessful."
* "[Patient] was admitted with standard precautions to monitor patient and environment for safety. [Patient] had 15-minute safety checks ..."
* "[No date] At 1010, a nursing communication was placed that allowed checks by monitor every 15 minutes ..."
* "[No date/time] A nursing note indicates that [patient] would not contract for safety after endorsing suicide plan 'since you put me on an NMI [mental illness hold]'. Concern for safety was emphasized with the patient."
* "On 11/17/2023, [patient] refused [their] morning 450mg of Lithium at 0826."
* "[No date/time] ... was notably anxious and unwilling to be interviewed by MD."
* "The following timeline was obtained from video footage ...:
- "12:20:52 Patient pulled a sheet out of [pillowcase] and then put it back ..."
- "12:22:50 Pulled out sheet from pillowcase again and replaced it in the pillowcase ..."
- "15:02:20 Patient retrieved the sheet from [their] pillowcase ..."
- "15:02:38 Patient placed the rolled sheet with a tied knot on the end over the room door ..."
- "15:02:56 Patient placed the sheet around [their] neck, then slowly sat down ..."
- "15:03:06 Patient rolls away from line of sight of camera ..."
- "15:05:42 Patient rolls back in view of camera."
- "15:08:33 Caregiver did a check in the alcove area ..."
- "15:19:57 Caregiver at alcove again ..."
- "[No time recorded] Caregiver visually rounding on camera - saw patient. Ran down hallway called code blue ..."
- "15:20:56 Room camera activated recording as clinical staff open door to patient on the floor with sheet around neck ... CPR commenced ..."
- "15:24:01 Code Blue team enters [BHU] hall"
- "[No time] Patient was found on the floor pulseless and not breathing. CPR started ... Code stopped at 15:45 and the patient was pronounced deceased."
* "According to PolicyStat, Use of Routine & Special Observation for Patient Safety ... q15 Minute Safety Checks: Direct observation of patient ensuring safety and location of patient on unit. Any unsafe behaviors and/or conditions will be addressed immediately and reported to assigned RN ... Staff assigned responsibility for conducting routine or special observations are to ... Routinely assess environment for potential risk factors impacting safety ... Staff assigned observation responsibilities are to notify patient's assigned RN or Charge RN immediately of any changes in patient's condition or environment that could potentially elevate safety risk for patient or others and intervene as clinically appropriate ... Patient's assigned RN or Charge nurse remains accountable for the decision to delegate patient observations. The RN must ensure that the staff member is sufficiently knowledgeable and competent to undertake observation responsibilities ... All patients admitted for inpatient care are subject to initial and ongoing multi-disciplinary risk assessments. The outcome of these individualized risk assessments will determine the level of observation, support and treatment prescribed. Ideally, a multi-disciplinary team should always make the decision about the level of safe and supportive observation needed. However, decisions may be made jointly by the physician and nurse. There may be the need to increase the level of observations in an emergency ... It is important to remember that all patients should be considered at risk ... High level of observation may be indicated, but not limited to, assessment of following factors ... History of previous suicide attempts ... When the patient is expressing thoughts and ideas about harming themselves ... Expressions of specific plans or intentions to harm themselves ... Patients who are withdrawn and/or difficult to engage ..."

3.a. Recorded video monitoring of the inside of Patient 13's room was reviewed on 11/29/2023 at 1220 with the PPM and PNM. It revealed:
* On 11/17/2023 at ~ 1101, no top sheet was observed on the patient's bed. This was confirmed with the PPM on 11/29/2023 at the time of this review.
* On 11/17/2023 at ~ 1502, the patient retrieved a sheet from [their] pillowcase, opened the room door, placed the sheet around their neck, and slowly sat or layed down.
* On 11/17/2023 at ~ 1521, staff entered the room and began CPR on the patient.

3.b. Recorded video monitoring of the inside of Patient 13's room and the hall outside of Patient 13's room recorded on 11/17/2023 from 0700 through the time of the incident was reviewed with the PNM on 11/29/2023 at 1445. It revealed:
* On 11/17/2023 at ~ 1508 and 1519, an MHA was observed at the alcove directly outside the door to the patient's room. There was no indication the MHA was aware of or noticed a sheet "with a tied knot on the end over the room door."
* No staff were observed going into Patient 13's room and conducting BH shift environmental rounds from 0700 through the time of the incident.
These findings were confirmed with the PNM on 11/29/2023 at the time of this review.

4. During an interview on 11/30/2023 at 1615 the EDO stated the hospital's ongoing internal investigation that included review of recorded video monitoring revealed that Patient 13 removed a bed sheet from their bed and placed it inside their pillowcase the day before the incident, on 11/16/2023 at 1500.

5. Patient 13's medical record was reviewed and reflected the patient was admitted to the hospital's inpatient BHU on 11/13/2023 with diagnoses that included suicidal ideation and PTSD. The medical record included the following:

* A nursing communication dated 11/13/2023 at 2150, and electronically signed by a physician on 11/14/2023 at 1010 reflected "May do checks by monitor."

* An RN note dated 11/13/2023 at 2223 reflected:
- "... 'I don't know how to bring myself back from an episode (panic attack) and all I can think of is to kill myself ...' Pt states [they] had a plan ... Pt has healed scars on L arm/antecubital area from past SA ... states [they have] PTSD from past trauma and states [they are] triggered by door opening on checks. Will do checks by monitor ..."
- "Suicide Risk: [Moderate]"
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by:
"STANDARD Precautions" and three interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety."

* A DO Psychiatry H&P note dated 11/14/2023 at 1323 reflected:
- "Patient was brought in by self to the emergency department stating that [they were] experiencing suicidal ideation with plans to jump off of an overpass. Patient was admitted to PPMC inpatient behavioral health for safety and further stabilization ... "
- "[Patient] found lying in bed in the dark ... states [they believe] [they need] to be in the hospital for safety and treatment and inquired about perhaps being civilly committed ... states [they are] worried [they] will attempt to leave the hospital before [they are] ready to go ..."
- "Risk Assessment: Recent self harm, Impulsivity, Persistent SI, and Fearful of Self-harm impulses"
- "Risk Level is estimated to be: Elevated"
- "Mental Status Examination: ... Eye contact is poor ... Mood/Affect: depressed and blunted Suicidal Thoughts: Active plan ... Thought Content: hopeless, helpless, and fear."

* An RN note dated 11/14/2023 at 2332 reflected "... Pt endorsed SI with a plan outside of the unit, pt would not disclose said plan. Pt verbally contracts for safety on the unit ... Safety checks q15 minutes."

* An RN note dated 11/15/2023 at 0956 reflected:
- "... [Patient] is mostly withdrawn to [their] room ... Endorsing thoughts of SI to jump off bridge ... contracts for safety on the unit ... Attended some evening groups."
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by:
"STANDARD Precautions" and three interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety."

* A DO Psychiatry note dated 11/15/2023 at 1542 reflected:
- "... Patient found lying in bed in the dark at the time of today's visit ... Patient reports that [they] did not sleep well overnight, which [they attribute] to noise from 15 minute checks as well as the door at the end of the hallway being opened and closed repeatedly. Patient reports that [they continue] to feel suicidal. Feels safe in the hospital but not safe outside of the hospital ... Assessment TODAY: Patient appears depressed and was difficult to engage in interview ..."
- "Risk Assessment: Impulsivity, Persistent SI, and Fearful of Self-harm impulses"
- "Risk Level is estimated to be: Elevated. This is due to continued severity of symptoms, continued suicidality ... dependence on the structure of the inpatient unit for safety."

* An RN "C-SSRS Daily/Shift Screen" dated 11/16/2023 at 0200 reflected "[unable to assess] pt asleep."

* An RN "C-SSRS Risk Assessment" dated 11/16/2023 at 0200 reflected:
- "Plans to Mitigate Risk for Suicide ... Checks every 15 minutes"
- "Clinical Team/LIP Overall Assessed Suicide Risk ... Moderate Risk"

* An RN note dated 11/16/2023 at 0225 reflected:
- RN Handoff Note ... Thoughts of Suicide: Yes ... Psych Precautions in Place: Suicide risk Safety Rounding: Q15."
- "Presentation: Behavior: Quiet ... Thought Process: Pressured, Impaired judgement ... Engagement with staff Interaction with Staff: Minimal ... Interaction with Peers: Withdrawn ..."
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by the same standard precautions and three interventions: STANDARD Precautions" and interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety."

* An RN note dated 11/16/2023 at 1422 reflected:
- "... [Patient] was up late this morning, c/o poor sleep last night and feeling tired ... denies SI/HI, 'not right now' ... was later seen pacing the hallways, reports anxiety, 'in my head and chest' ... accepted zyprexa, vistaril and tylenol, reports not helpful, requested for 'more medications', MD notified. Pt later requested to discharge, was placed on NMI [mental illness hold], accepted information without any incident."
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by the same standard precautions and three interventions: STANDARD Precautions" and interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety." There was no documentation that reflected the RN evaluated the standard precautions and interventions and determined they remained appropriate considering the patient was placed on an NMI (mental illness hold).

A DO Psychiatry note dated 11/16/2023 at 1623 and electronically signed by the DO 11/16/2023 at 1629 reflected:
* "Time patient seen: 0930 and 1430"
* "... Patient found lying in bed in the dark at the time of today's visit ... Continues to feel depressed and suicidal, does not feel safe outside the hospital ... Later in the day, this author was notified that patient wish [sic] to leave the hospital. Presented to patient's room for reevaluation. [Patient] states that [they are] experiencing pain and anxiety and would like to leave ... Discussed with patient that given recent report of active SI and concerns about impulsivity/impaired judgment, [they] would be placed on NMI [mental illness hold]. Asked patient if [they] would like this author to restart Lyrica, which [they] had taken in the past, however [they] stated that medication did not work and did not definitively answer ..."
* "Mental Status Examination ... Patient seen in patient's room ... Suicidal Thoughts: Active plan"
* "Current level of care need: Patient meets the following criteria for continued stay: Danger to Self or Others and Need for close Medication Management"
* "Assessment TODAY: Patient continues to appear depressed and continues to report active suicidal ideation. Patient later requested to discharge however given ongoing SI, will place on NMI [mental illness hold] ... In reviewing the overall clinical picture, patient appears to be showing no change in symptoms today."
* "Chemical Dependency ... Continue Safety Checks per our protocol."
* "Risk Assessment: Impulsivity, Persistent SI, and Fearful of Self-harm impulses ... Risk Level is estimated to be: Elevated. This is due to continued severity of symptoms, continued suicidality, dependence on the structure of the inpatient unit for self care, and dependence on the structure of the inpatient unit for safety." Although the DO documentation reflected the patient was placed on an NMI (mental illness hold) due to "recent report of active SI and concerns about impulsivity/impaired judgment," there was no documentation that reflected the precautions and interventions in place at that time were evaluated, and determined still appropriate.

* An RN "C-SSRS Daily/Shift Screen" dated 11/16/2023 at 2030 reflected:
- "Thoughts of Suicide ... Yes"
- "Since you were last asked, have you actually had thoughts about killing yourself? ... Yes"
- "Have you been thinking about how you might kill yourself? ... Yes"
- "Have you had these thoughts and had some intention of acting on them? ... No"
- "Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? ... No"
- "Have you done anything, started to do anything, or prepared to do anything to end your life? ... No"
- "Describe: ... will not elaborate and states will not talk to staff upset about NMI [mental illness hold]."
The suicide screen documentation failed to describe what aspects of the suicide screen the patient would not talk about.

* An RN "C-SSRS Risk Assessment" dated 11/16/2023 at 2030 reflected:
- "Plans to Mitigate Risk for Suicide ... Checks every 15 minutes."
- "Clinical Team/LIP Overall Assessed Suicide Risk ... Moderate Risk."
There was no documentation that reflected the RN evaluated the plan to mitigate the patient's risk for suicide and determined it was still appropriate taking under consideration that the patient would "not elaborate" and would not talk to staff during the C-SSRS Daily/Shift Screen.

* An RN note dated 11/16/2023 at 2136 and filed at 2142 reflected:
- "... [Patient] has been pacing, appears anxious, depressed and is guarded and irritable. Minimal contact with peers. C/o pain in back and denies interventions 'nothing you can give me works, what's the point?' [Patient] endorses SI with plan which [they] will not disclose and further states that [they] would not contract for safety since 'you put me on an NMI [mental illness hold]'. This writer emphasizes our concern for [their] safety ..."
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by the same standard precautions and three interventions: "STANDARD Precautions" and three interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety."

Although the patient endorsed SI with a plan, would not disclose the plan, and would not contract for safety, there was no documentation that reflected the RN evaluated the precautions and interventions in place at that time and determined they remained appropriate. There was no documentation that reflected the RN notified the charge nurse or physician of the patient's refusal to talk to staff during the C-SSRS Daily/Shift Screen, nor that the patient endorsed SI with a plan and would not contract for safety. There was no documentation that reflected the RN evaluated whether the patient should use a safety blanket or the bathroom door should be locked for "Moderate Risk" in accordance with the "Standard Work Document" titled "OPH IP BH Mitigation Plans for Ligature Points" in finding 10.h. There was no documentation that reflected the RN evaluated the current plan of standard precautions with optional remote monitoring, to ensure it remained appropriate.

* A "Behavioral Health Observation Form" dated 11/16/2023 was reviewed and was incomplete and failed to identify the patient's risk for suicide and the sheet inside the patient's pillowcase. Examples included:
- The top of the forms had pre-printed "Risk for:" Just below this there were check boxes next to each of the following:
"Suicide"
"Self-Harm"
"Violence"
"Wandering"
"Sexual"
"Behavior"
"Fall"
"Elopement" and
"Observed Behavior(s)."
All of the check boxes were blank. Although the patient had been withdrawn, appeared depressed, and acknowledged thoughts of suicide, none of the check boxes at the top of the form were checked indicating the patient's risk, including risk for suicide.
Another section on the top of the form had pre-printed patient location codes. Those were:
"D = Day room"
"SH = Shower"
"IR = Interview Room"
"SR = Seclusion Room"
"S = Sensory Room"
"R = Room"
"BR = Bathroom"
"GP = Group Room"
"H = Hallway"
"MW = Med Window"
"Off = Off Unit"
The form included pre-printed times every 15 minutes from 0000 through 2345. After each 15-minute time, there were spaces for recording patient location code, patient behavior code, and staff initials. "R" for "[Patient] Room" and staff initials were recorded indicating staff made observations approximately 26 times between 11/16/2023 at 1500, the time the patient put a sheet inside their pillowcase, and 11/16/2023 at 2345. However, there was no documentation that staff noticed the sheet or removed the sheet during any of those times.

* An RN note dated 11/17/2023 at 0620 reflected:
- "Behaviors this shift: slept ... Assumed care for pt from 2300-0730 hrs. Slept mostly during shift. No unsafe behavior noted. Denies SI/HI/AVH."
- "Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol" followed by the same precautions and interventions:
"STANDARD Precautions" and three interventions, "SW to establish Safety support/Relapse plan with family/significant others," "SW to evaluate access to firearms," and "Monitor patient & environment for safety."

* A DO Psychiatry noted dated 11/17/2023 at 1123 and electronically signed by the DO 11/17/2023 at 1615 reflected:
- "Time Seen: 0930"
- "Patient found lying in bed in the dark at the time of today's visit. Greeted patient however [they] did not answer. Walked around to direction patient was facing to assess whether or not [they were] sleeping. Patient's eyes noted to be open and blinking. Attempted to engage patient in interview again however [they] replied that [they] did not feel like speaking today. Patient did not answer any assessment questions asked."
* "Mental Status Examination ... Patient seen in patient's room ... Eye contact is poor ... Speech: slow and quiet ... Mood/Affect: depressed and blunted ... Suicidal Thoughts: Would not answer ... Homicidal Ideations: Would not answer ..."
* "Assessment TODAY: Patient poorly engaged in interview today. Appeared to be irritable and depressed and would not answer assessment questions. Terminated interview shortly after contact. Will continue current medications at current doses for today and continue to assess ... In reviewing the overall clinical picture, patient appears to be showing no change in symptoms today."
* "ADDENDUM: This author was paged later in the afternoon by patient's nurse, informing this author that patient had been found hanging from a bedsheet in [their] room. Patient seen by rapid response team and stabilization was attempted however patient ultimately died."
Although the documentation reflected the patient was depressed, would not answer any assessment questions, including those related to suicidal thoughts, there was no evaluation of the current plan and interventions which included the same standard precautions with monitoring every 15 minutes and optional "checks by [video] monitor."

* An RN note dated 11/17/2023 at 1554 reflected "Code Blue called at 15:23. Pt found on the floor pulseless and not breathing ..."

* Review of a "Behavioral Health Observation Form" dated 11/17/2023 included the same pre-printed information as above. Similarly, all of the check boxes after "Risk for:" were blank including "Suicide. "R" for "[Patient] Room" and staff initials were recorded indicating staff made observations approximately 57 times between 11/17/2023 at 0000 and 11/17/2023 at 1515 (eight minutes before the code blue was called). However, there was no documentation that staff noticed the sheet inside the pillowcase or removed the sheet during any of those 57 times.

6. During interview on 11/30/2023 at 1300 with a Psychiatrist and other hospital leadership present the following information was provided:
* The Psychiatrist stated Patient 13 had a lot of risks for suicide including family history of suicide, SI, and houselessness.
* The Psychiatrist stated increased monitoring should be considered when a patient has "red flags." The Psychiatrist stated "red flags" included when a patient "is having active suicide," "says they have a [suicide] plan," "cannot contract for safety," and "has a change of status."
* Regarding the RN note filed on 11/16/2023 at 2142, the Psychiatrist stated this was a change for the patient, the best person to address this was the nurse, and there was no documentation that reflected the nurse notified the physician of this change.

7. During interview and review of Patient 13's medical record on 11/30/2023 at 1400 with EDO, CNO, ANM and other hospital leadership the following information was provided:
* Patient 13 was on "standard" every 15 minute observation monitoring at the time of the incident, and the medical record included an order that permitted staff to conduct every 15 minute observation monitoring by video monitor.
* Regarding the RN note filed on 11/16/2023 at 2142, the RN should have notified the charge nurse and the physician about the patient's suicide risk including that the patient endorsed SI with a plan, and would not contract for safety.
* The ANM confirmed there was no documentation that reflected the RN notified the charge nurse or the physician that the patient endorsed SI with a plan, and would not contract for safety.
* The ANM confirmed there was no documentation that reflected the RN evaluated the patient for possible increased monitoring or other interventions regarding the patient's change and risk for suicide, nor that the care plan had been modified.

8.a. A "Behavioral Health Shift Environmental Rounds" form for the inpatient BHU dated 11/17/2023 was reviewed and was incomplete and failed to identify the missing sheet on the patient's bed and the sheet inside their pillowcase. Examples included:
* Instructions at the top of the form reflected "The below form is completed at the start of each shift (0700 & 1900) and placed in the Environmental Rounds binder kept in the nurses station. Documentation of this rounding form is to be completed by two staff, both staff need to print name, initial and put time this was completed."
* The form included spaces for recording staff initials and specific times BH shift environmental rounds were completed. One of sections on the form included, "All Patient rooms and bathrooms visualized for safety concerns ... Obstacles blocking entrance ... Contraband items ... Possible ligature risks ... [e.g.], knotted sheets, torn towels)." The form had only one set of initials and no time recorded under "0700 Initials/Time." There were no initials and no time recorded under "1900 Initials/Time."
* The bottom of the form reflected "2 Staff Initials" followed by one set of initials, and "2 Staff Print" followed by one staff name and title. There was no documentation that reflected the rounding form was completed by two staff in accordance with the instructions at the top of the form.

8.b. During an interview on 11/29/2023 at 1430 the PNM stated BH shift environmental rounds should be conducted by staff each shift. The PNM stated that when staff conduct environment rounds "They should be looking around the [patient's] room." The PNM also stated staff should notice if a sheet is inside a pillowcase.

8.c. Although the "Behavioral Health Shift Environmental Rounds" form in finding 8.a. was initialed and dated indicating one staff had conducted environmental rounds on 11/17/2023 at or around 0700, review of recorded video monitoring of the inside of Patient 13's room in finding 3.b. revealed no staff conducted BH shift environmental rounds inside Patient 13's room from 11/17/2023 at 0700 through 11/17/2023 at the time of the incident.

8.d. During interview on 11/30/2023 at 1615, the EDO stated they spoke with staff and confirmed that although documented as having been conducted, staff had not conducted BH unit environmental rounds on 11/17/2023 at or around 0700.

9.a. A "Purposeful Rounding Log" dated 11/17/2023 for Patient 13 was reviewed and was incomplete and failed to identify the patient's risk for suicide and knotted sheet inside their pillowcase. Examples included:
* The top of the form had pre-printed "Risk:" followed by a space. There was nothing recorded in this space nor anywhere else on the log that reflected the patient's suicide risk. Just below this there were check boxes next to each of the following:
- "Suicide"
- "Self-Harm"
- "Violence"
- "Wandering"
- "Sexual"
- "Behavior"
- "Fall"
- "Elopement" and
- "Observed Behavior(s)."
The form included pre-printed times every hour from "07" through "23." After each one hour time, there was a space for recording:
- "Time" in minutes to complete the pre-printed hour time.
- "[Staff] Initials"
- "Patient Activity"
- "Location"
- "Behavior"
- "[C] Comfort & Pain"
- "[A] Anticipate Needs"
- "[R] Risks/Assessment"
- "[E] [Environment]/Elimination" and
- "[S] Sensitivity & Safety"

For "07" spaces for recording the following were blank:
- "Time" in minutes to complete the pre-printed hour time.
- "Patient Activity"
- "[C] Comfort & Pain"
- "[A] Anticipate Needs"
- "[R] Risks/Assessment"
RN initials were entered next to "07".
"[E] [Environment]/Elimination" and "[S] Sensitivity & Safety" were checked. However, there was no documentation that reflected the RN noticed the missing sheet from Patient 13's bed or the knotted sheet inside the patient's pillowcase.

For "0828," spaces for recording the following hourly rounding were blank:
- "Patient Activity"
- "[C] Comfort & Pain"
- "[A] Anticipate Needs"
- "[R] Risks/Assessment"
- "[E] [Environment]/Elimination" and
- "[S] Sensitivity & Safety"
RN initials were entered next to "0828"
There were similar blank spaces and RN initials next to 0915, 1003, 1112, 1202, and 1305. All spaces for recording hourly rounding at 1400 and 1500, were blank. Refer to finding 2 that reflects the patient retrieved a sheet from their pillowcase at 1502 and CPR commenced at 1520.
The bottom of the form had initials and names of two RNs.

A section below this reflected "Other Known Risk(s)" followed by:
- "Suicide"
- "Self-Harm"
- "Violence"
- "Wandering"
- "Sexual Behavior"
- "Fall"
- "Elopement"
- "Observed Behavior(s):
All of these were preceded by a blank check box, including "Suicide."

9.b. During interview and review of purposeful rounding documentation with hospital staff on 11/28/2023 at 1420, they stated CARES rounding was documented hourly by nurses on the "Purposeful Rounding Log" in finding 9.a.

10.a. An undated "Standard Work Document" titled "OPH IP BH Day Charge RN Workflow," Version 1.0, reflected "Start of Shift ... Ensure that Environmental Rounds are assigned."

10.b. An undated "Standard Work Document" titled "OPH IP BH Evening Charge RN Workflow," Version 1.0, reflected "Start of Shift ... Ensure that Environmental Rounds are assigned."

10.c. An undated "Standard Work Document" titled "OPH IP BH MHA Noc SW," Version 1.0, reflected "MHA Night Routine ... Complete environmental rounds at start of shift ..."

10.d. The "MHA Orientation Packet" provided included a document titled, "Behavioral Health Shift Environmental Rounds" dated "Oct 2018." It reflected "The Behavioral Health Shift Environmental Rounds will be conducted at the onset of each shift. Responsibility of completion of this form can be a MHA or RN and assigned by the charge nurse ... The purpose of the environmental rounds is to review all areas of the unit to assess for and [sic] safety concerns as they could potentially cause patient harm. After completion of the 24-hour form they will be stored in a designated binder and housed in the Nurse Manager's office ... Begin October 29, 2018."

10.e. A P&P titled, "Searches of Patient Environment" dated "Effecti

Based on interviews, review of medical record documentation for 5 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, and 10), review of incident documentation for 13 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 14), review of P&Ps, review of environmental rounds documentation, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings included:

1. The P&P titled "Event Reporting Using DATIX (Unusual Occurrence Reporting - UOR)" dated "02/2023" was reviewed and included the following:
* "When an unusual occurrence is discovered, the individual involved in the event and/or the individual discovering the event will complete a Datix Event Record as soon as possible so that details will not be forgotten. It is expected that anytime an event of serious consequences occurs, the person who becomes aware of the event will notify their supervisor/manager immediately to provide assistance and take actions, if appropriate. The supervisor/manager should contact Quality Management as soon as possible. Action will be taken as appropriate to reduce any immediate danger to patients, visitors, or staff."
* "The Datix Event Record will be reviewed by the unit manager or department head (or designee) who is responsible to investigate the situation, take actions as indicated, follow-up with applicable staff, and document their findings on the Datix Event Record. This individual also reviews the Datix Event Record for completeness and accuracy and submits the completed record within 30 days."

2. Regarding Patient 1, incident investigation documentation reflected that on 01/04/2023 at 1957 "Patient [1] approached another patient that was watching the TV and strikes/attached [sic] [them] 3 times unprovoked."
* The "Date closed (MM/dd/yyyy)" reflected "02/13/2023"
* The "Contributing Factors section reflected "Cognitive Impairment/Dementia"
* The "Harm Level" section reflected "No Detectable Harm"
* "List witnesses and/or others involved including their role ... List names and how involved" was followed by "[Another patient] was the patient attached [sic] by [Patient 1]. [Patient 1] attacked him thrice [sic] before [they] pushed [them] away. [The other patient] pushed [Patient 1] away the first time but [Patient 1] was still coming ... then [the other patient pushed Patient 1] to the floor a second time."
* The "Investigation Components" section was followed by seven items:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
The only item checked was "Discussed with Care Team".
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by "02/13/2023 Per reports the incident appeared to be unprovoked and the two patients had minimal interaction. No injury to assaulted patient. Patient was moved to a different floor. Security (code grey) called and patient was escorted away from the situation after unsuccessful attempts by staff."
* The section "Submitter's Actions Taken and Recommendations for Prevention" reflected "APS report done, code grey called and email sent out to BH staff. [Patient 1] was told not to walk on E hallway"
* The section "Deviation from GAPS" reflected "None"
* The section "Action" reflected "APS filed Code grey called Seclusion for attacker Separated patients to two separate floors Medicated attacking patient"

The documentation lacked a clear and timely investigation. For example:
* The incident occurrence date was 01/04/2023. Investigation findings were dated "02/13/2023," more than 30 days later. The documentation lacked evidence the investigation was completed within 30 days in accordance with hospital policy.
* The "List witnesses ..." section did not include witness name and how involved.
* The "Investigation Components" section reflected "Discussed with Care Team." It was unclear what was discussed and the outcome of the discussion.
* The documentation reflected "Per reports the incident appeared to be unprovoked." However, it was not clear who reported, what was reported and when.
* There was no investigation that reflected whether abuse or neglect were ruled out.
Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients.

3.a. Regarding Patient 2, incident investigation documentation reflected that on 01/09/2023 at 1530 "Pt with feces in [their] depends. Possibly for several days ... [Patient's representative] said that [they] had just talked to [patient] ... [patient] told [them] that [they had] been incontinent and had been lying in [their] own feces for several days. I immediately went down to [their] room to check on [them]. [They] did have feces in [their] depends. [They were] given a shower. RN checked ... to make sure all feces were cleaned up ... Bedding was changed ... Pt reported ... that [they] did not know that [they were] having a bowel movement ..."
* The "Harm Level" section reflected "No Detectable Harm"
* The "List witnesses and/or others involved including their role" section was blank.
* The "Investigation Components" section was followed by seven choices:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
Only "Reviewed Chart" was checked.
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by only "No progress notes."
* The "Deviation from GAPS (Generally Accepted Performance Standards)" section reflected "Please describe any deviations in practice (GAPS) found during your investigation." This was followed by "protocol."
* The "Actions" section reflected:
- "patient was assessed by the RN and CRN"
- "Assisted with ADLs"
- "Communicated bowel concerns with MD"

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&P. For example:
* The documentation reflected the patient reportedly had been lying in [their] own feces for several days. However, there was no investigation that reflected BHU staff were interviewed or other follow up investigation to determine when staff had last checked the patient for elimination and hygiene needs.
* There was no investigation that considered the patient's history of laying in feces and urine. Refer to finding 3.c. below.
* There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps as applicable. For example, P&Ps related to elimination and hygiene needs, RN evaluation and supervision, and care planning.
* There was no evaluation of potential deviation from GAPS, nor follow-up if deviations had occurred.
* There was no investigation that reflected whether abuse and neglect were ruled out.
* The only follow up actions were patient-specific and did not address how similar incidents would be prevented for other patients.
* There was no documentation of further investigation or follow-up actions.
Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients.

3.b. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 2 was categorized as "Neglect."

3.c. The medical record for Patient 2 reflected the patient was admitted to the BHU on 12/24/2022 with diagnoses that included major depressive disorder. The medical record included:

* An MSW note dated 12/25/2022 at 1525 reflected "... In the last month, patient has been laying in bed, going to the bathroom, and then continuing to lay in feces and urine for days. Patient reports that [they] can't control [their] bowel movements ..."

* An MD note dated 01/05/2023 at 1218 reflected "Complains of constipation. We will start fiber supplement ..."

* Flowsheet documentation dated 01/07/2023 at 0404 reflected "Hygiene ... Level of Assistance ... Declined by patient."

* An RN note dated 01/07/2023 at 0623 included no information about the patient's elimination or personal hygiene needs.

* Flowsheet documentation dated 01/07/2023 at 1208 reflected "Hygiene ... Level of Assistance ... Declined by patient."

* An RN note dated 01/07/2023 at 1807 reflected:
"Personal hygiene/ADLs" followed by a blank space.
"Compliance with care/meds" followed by a blank space.

* Flowsheet documentation dated 01/07/2023 at 2049 reflected "Hygiene ... Level of Assistance ... Declined by patient."

* An RN note dated 01/08/2023 at 0606 reflected "Personal hygiene/ADLs ... Declines; Needs prompting."

* Flowsheet documentation dated 01/08/2023 at 0848 reflected "Disheveled ... Poor hygiene."

* An RN note dated 01/08/2023 at 1735 reflected:
"Personal hygiene/ADLs" followed by a blank space.
"Compliance with care/meds" followed by a blank space.
"... refusing to use urinal ..."

* An RN note dated 01/09/2023 at 0622 reflected:
"Personal hygiene/ADLs" followed by a blank space.
"Shift Note: ... Mostly [isolative] to room ... Expressed no issues voiding."

* Flowsheet documentation dated 01/09/2023 at 1728 reflected "Disheveled ... Poor hygiene."

An RN note dated 01/09/2023 at 1825 reflected "DCN received a phone call from [patient's representative]. [Patient's representative] stated that pt told [them] that [they had] been incontinent and [had] been lying in [their] own feces for several days. DCN checked in with pt. [Patient] could not say why [they] had not told staff that [they were] having incontinence or that it had been there. [Patient] was asked to take a shower to clean up. Large amount of solid feces in [their] depends and some on the shower room floor ..."

The care plan was generic and lacked individualized, patient-specific goals and interventions based on a comprehensive RN assessment of the patient's elimination and hygiene needs. Examples included:
* Flowsheet care plan documentation dated 12/27/2022 at 1547 reflected "Individualized Care Needs ... need reassurance and prompted for daily self care ..."
* Flowsheet care plan documentation dated 01/11/2023 at 1442 reflected "Care Plan Interventions ... Supportive Measures ... active listening utilized; decision-making supported; positive reinforcement provided; self-care encouraged; verbalization of feelings encouraged."
* Flowsheet care plan documentation dated 01/12/2023 at 1424 reflected "Care Plan Interventions ... active listening utilized; decision-making supported; positive reinforcement provided; self-care encouraged; verbalization of feelings encouraged."
* Flowsheet care plan documentation dated 01/26/2023 at 0948 reflected "Care Plan Interventions ... active listening utilized; decision-making supported; goal-setting facilitated; positive reinforcement
provided; self-care encouraged; self-reflection promoted; self-responsibility promoted; verbalization of feelings encouraged."
* Additional Care Plan documentation reflected:
- "Problem: Constipation"
- "Goal: Effective Bowel Elimination"
- "Intervention: Promote Effective Bowel Elimination"
- "Promote activity and mobility. Establish regular, unhurried time for elimination. Promote privacy and comfort; position to facilitate elimination. Continue home bowel regimen, if possible. Encourage fluid intake and adequate dietary fiber. Evaluate factors that may contribute to constipation (e.g., iron supplement, opiate, pain, fear); anticipate need for stool softener. Monitor stool characteristics, abdominal girth, bowel sounds, expression of symptoms and relief." The care plan lacked patient-specific, individualized goals and interventions related to the patient's history of and ongoing incontinence, need for hygiene assistance. The care plan also did not include the patient's refusal of hygiene and individualized interventions to address this.

3.d. During an interview and review of the incident documentation with the PNM and other hospital leadership on 12/01/2023 at 1445, the PNM confirmed there was no investigation that reflected how long the patient "had been lying in [their] own feces" as reported.

3.e. During an interview and review of the medical record with the ANM and other hospital leadership on 12/01/2023 at 1725, the ANM confirmed the lack of individualized, patient-specific nursing care plan regarding the patient's elimination and hygiene needs.

4.a. Regarding Patient 3, incident investigation documentation reflected that on 01/28/2023 at 1845 the patient was ambulating in the hallway "when another patient pushed [them], causing [them] to fall and hit [their] head."

* The "Harm Level" section reflected "Initial impression of the extent of harm at the time of the event ... Minimal Harm"
* The "List witnesses and/or others involved including their role" section was blank.
* The "Investigation Components" section was followed by the same seven choices as the above findings.
"Discussed with Care Team" and "Reviewed Chart" were checked.
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by "Situation ... [another patient] pushed [Patient 3] in the hallway which resulted in [Patient 3] hitting [their] head on the wall."
* The "Actions" section reflected "Redirect [Patient 3] to [their] room, Vitals stable, Neuro checks WNL, given pain medication, and monitoring."
* The "Recommendations for prevention" section was blank.
* The "Deviation from GAPS (Generally Accepted Performance Standards)" section reflected "Please describe any deviations in practice (GAPS) found during your investigation." This was followed by "n/a."
The "Recommendations" section reflected "Code Grey, locked seclusion for [other patient] ... [other patient] given IM medications ... APS contacted, filed report ... [Patient 3] medicated and assessed: No additional orders submitted for any injuries. Patient c/o HA, but declined any other discomfort ... VS stable, Neuro checks WDL ... [Patient 3] did not want to press any charges ... Current hallways safest for each patient, increasing staff rounding and staff presence in hallways ... Behavioral plans adjusted a [sic] clinically required ..."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* The documentation was unclear whether the other patient involved in the incident was injured.
* There was no investigation that reflected the incident was unavoidable.
* There was no investigation that reflected whether abuse or neglect were ruled out.
* There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps, as applicable. Although the documentation reflected "Neuro checks WDL" there was no investigation that reflected whether appropriate P&Ps were followed. For example, implementation of locked seclusion and neuro checks considering Patient 3 fell and hit their head.

4.b. The medical record of Patient 3 reflected the patient was admitted to the BHU on 12/03/2022 at 1215 with a diagnosis of schizoaffective disorder.

An RN note dated 01/28/2023 at 1943 reflected "Today at 1845 [Patient 3] was pushed by [another] patient ... causing [Patient 3] to fall. [Patient 3] reported hitting [their] head but denied other concerns ... neuro checks WNL, and [they were] ambulating without difficulties. Given pain medication ..." There was no further assessment of the patient after the fall, including assessment of their head for injuries or ROM.

The first RN documentation of a neurological assessment after the incident was 01/28/2023 at 1945, an hour after the incident and it reflected:
- "Cognitive/Neuro/Behavioral ... WDL except; orientation"
- "Orientation ... disoriented to; situation"
Although the neurological assessment suggested the patient's "orientation" was not within defined limits, and the patient was disoriented to "situation," there was no RN documentation of a follow up neurological assessment for at least the next 24 hours.

The next RN note dated 01/29/2023 at 0057 reflected "Patient was pacing the halls this evening with blunted restricted affect ... took cyclobenzaprine prn
neck/shoulder pain/spasms/tightness. Patient is seen walking with hunched over back ..."

4.c. During an interview and review of Patient 3's medical record with the ANM and other hospital leadership on 12/01/2023 at 1715, the ANM confirmed the lack of RN assessment, including head, neurological, and ROM.

5.a. Regarding Patient 4, incident investigation documentation reflected that on 02/11/2023 at 1915 "When doing the 15 min checks I opened [Patient 4's] door and [they were] sitting at the bedside holding a sheet that [they] tied a knot into like a noose. I alerted charge RN and other night shift staff. Patent was moved to [seclusion room] and given a safety blanket and a pillow and was asked to remain in [seclusion room] for safety concerns. I removed all personal bedding from [room number] (room where patient is assigned)."
* The "Contributing Factors" section reflected "... Other ... hearing voices."
* The "Harm Level" section reflected "Near Miss/Good Catch."
* The "Investigation Components" section was followed by seven choices:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
Only "Discussed with Care Team" was checked.
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by only "Patient made noose from sheet."
* The "Deviation from GAPS (Generally Accepted Performance Standards)" section reflected "n/a."
* The "Actions" section reflected "Unit suicide interventions were taken: patient moved to a safety room with no linen, and the linen from their room have been replaced. Patient on Q15 monitoring. Safety blanket provided for comfort/warmth. Patient staying in safety room with safety blanket."
There was no documentation of further investigation or follow-up actions.

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&P. For example:
* Although the documentation reflected the patient was observed "sitting at the bedside holding a sheet that [they] tied a knot into like a noose," there was no investigation that reflected when staff last checked the patient and what the patient was doing at that time including whether they had previously exhibited unsafe activities involving sheets.
* There was no investigation that reflected BHU staff were interviewed or other follow up investigation to determine when staff had last checked the patient.
* There was no investigation that reflected whether recorded video monitoring was reviewed.
* There was no investigation that reflected whether BH shift environmental rounds had been conducted prior to the incident and whether any unsafe items, such as knotted sheets, had been identified in the patient's room and whether actions had been taken, if any found.
* There was no investigation that reflected what the patient's self-harm and suicide risk were before the incident.
* There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps as applicable. For example, P&Ps related to self-harm and suicide risk including C-SSRS suicide risk level, patient access to bed sheets, observation and monitoring, BH shift environmental rounds; and RN evaluation, supervision, and care planning.
* There was no evaluation of potential deviation from GAPS, nor follow-up if deviations had occurred. GAPS documentation reflected only "n/a.."
* There was no investigation that reflected whether abuse and neglect were ruled out.
* The only follow up actions were patient-specific and did not include an evaluation of possible gaps in P&Ps or staff actions that may have contributed to the incident.
Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients.

5.b. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 4 was categorized as "Self Harm."

5.c. The medical record for Patient 4 was reviewed and reflected the patient was admitted to the BHU on 02/10/2023 with diagnoses that included bipolar, psychosis, suicidality, and SI. The medical record included:

* An RN note dated 02/11/2023 at 1927 reflected "[Patient] was in [their] room most of the shift, isolative and restrictive ... in a depressed mood and has flat hostile affect ... pt decline [sic] to attend groups, at 1915 pt was having suicidal ideation ... crying and stated 'I am hearing voices, the voices are telling me to hung [sic] myself' ..."

* The next C-SSRS Suicide Risk Level was documented by the RN on 02/11/2023 at 2200. That documentation reflected "Self Injurious Behavior ... during shift change, patient was observed testing self-harm methods. placed in safety room ..."

5.d. Review of BH shift environmental rounds documentation reflected no documentation that those had been conducted in accordance with hospital P&Ps during the entirety of Patient 4's BHU hospitalization from 02/10/2023 through 02/14/2023. Refer to Tag A144 that reflects BH shift environmental rounds were to be completed and documented by two staff each shift and were intended to identity unsafe items in the physical environment, including knotted sheets and other items in patient rooms and throughout the BHU.

5.e. During an interview and review of the incident documentation with the QA RN and other hospital leadership on 12/01/2023 at 1245, QA RN confirmed there was no further investigation documentation.

6. Regarding Patient 5, incident investigation documentation reflected that on 05/25/2023 at 1445 "Named patient [Patient 5] went into group without permission and when asked to leave struck another ... patient on the back or back of head with an open hand while leaving group room."

* The "Harm Level" section reflected "No Detectable Harm"
* The "Contributing Factors section reflected "Altered Mental Status ... Cognitive Impairment/Dementia"
* The "Investigation Components" section was followed by seven items:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
Only "Other ... Duplicate event" was checked.
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by
- "05/30/2023 See linked incident for review and investigation findings."
The section "Submitter's Actions Taken and Recommendations for Prevention" reflected:
- "APS notified @1649 ..."
- "Datix"
- "Leadership"
- "Order for patient to be on 1:1"
- "MD increasing medications"
- "No groups for patient at this time"
- "Offered for patient assaulted to file charges"
- "Talked with patient to reinforce unit expectations, Medicated Pt"
The section "Recommendations for prevention" reflected: "Keep group room locked when in session"
The section "Linked Records ... Linked Event (1)" reflected: "[Patient 6] was sitting participating in group and unprovoked a ... peer struck [Patient 6] in the back of ... head with ... hand. [Patient 6] denies any injury and does not believe the patient meant ... harm ... and believed that [Patient 5] was joking. Staff separated them, [the] peer was medicated and spent time in the room while the team safety planned. APS was notified and the peer was placed on 1:1. [Patient 6] at this point does not want to press charges. [Staff] Reports [they] did a UOR on the peer."

The documentation was unclear and inconsistent. For example:
* The incident was reported in two separate incident reports, each with a different incident time. The time of the incident recorded for Patient 6 in Finding 7 was 1500. The time of the incident recorded for Patient 5 was 1445. It was not clear whether an incident occurred at 1445, 1500 or both times. If an incident occurred at 1445 and 1500, it was unclear if actions were taken after the 1445 incident to prevent reoccurrence at 1500.
* Investigation findings reflected that Patient 5 "has been presenting with intrusive behaviors ..." This information was not reflected in Patient 5's incident report but was reflected in the incident report for Patient 6.
* There was no investigation that reflected whether abuse and neglect were ruled out.
Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients.

7. Regarding Patient 6, incident investigation documentation reflected that on 05/25/2023 at 1500 "[Patient 6] was sitting participating in group and unprovoked a ... peer struck [Patient 6] in the back of ... head with ... hand. [Patient 6] denies any injury and does not believe the patient meant ... harm ... and believed that [Patient 5] was joking. Staff separated them, [the] peer was medicated and spent time in the room while the team safety planned. APS was notified and the peer was placed on 1:1. [Patient 6] at this point does not want to press charges. [Staff] Reports [they] did a UOR on the peer."

* The "Harm Level" section reflected "Minimal Harm"
* The "Investigation Components" section was followed by seven items:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
Three of the seven items were checked: "Conducted Interview(s) ... Discussed with Patient ... Reviewed Chart".
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by
- "05/26/2023 Situation: [Patient 5] ... assaulted [Patient 6] as [they] were leaving the group room by hitting [Patient 6] on the back of [their] head."
- "Background: [Patient 5] with reported psychiatric history of ... at the time of incident, was on a NMI [mental illness hold] due to altered mental status. Patient has a history of violence prior to admission, throwing objects at others, disrobing ... [Patient 6] ... with reported psychiatric history of ... worsening AH. Patient is voluntary and has been compliant with [care] ... attends groups and is medication compliant, with a violence history, but no presentation of aggressive behaviors towards staff/peers during this admission."
- "Assessment: [Patient 5] has been presenting with intrusive behaviors during this admission ..."
- "Recommendations: Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ... APS report filed ... [Patient 6] did not want to press charges ..."
* The "Actions" section reflected "05/26/2023 Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ... APS report filed ... [Patient 6] did not want to press charges ... Datix submitted"

The documentation was unclear, and the investigation did not address specific findings or behavioral concerns on the part of Patient 6 which may have contributed to this incident. For example:
* Investigation findings reflected that Patient 5 "has been presenting with intrusive behaviors ..." The investigation does not verify whether any previous interactions had occurred between Patient 5 and Patient 6 which may have contributed to the incident.
* The follow up actions reflected "Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ..." reflected actions that were taken for Patient 5. However, there were no actions taken for Patient 6 and it was unclear whether any actions were needed. It was additionally unclear what "official 1:1" meant. It was unclear whether the patient was on unofficial 1:1 or other monitoring prior to the incident.
* The documentation was patient-specific and lacked investigation that reflected the incident was evaluated for compliance against applicable P&Ps. For example, policies related to observations, monitoring and supervision.
* There was no investigation that reflected whether abuse and neglect were ruled out.
Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients.

8.a. Regarding Patient 7, incident investigation documentation reflected that on 05/30/2023 at 1830 "Pt. was secluded at 1745 for aggression at time of admission. Shortly after [they were] observed punching ceiling in seclusion room. [Patient] had then concealed a safety screw that [they] had dislodged from ceiling around light fixture and proceeded to scratch both security cameras to completely obstruct view. As pt. admitted with active suicidal ideation and hx of assault it was determined that the screw needed to be removed from the pt. ASAP."
* The "Harm Level" section reflected "Initial impression of the extent of harm at the time of the event ... No Detectable Harm."
* The "Investigation Components" section was followed by seven items:
- "Conducted Interview(s)"
- "Discussed with Care Team"
- "Discussed with Patient"
- "Examined Physical Location"
- "Reviewed Policies/Procedures"
- "Reviewed Chart"
- "Other"
All items were checked except "Discussed with Patient."
* The "Investigation Findings" section reflected "Please summarize the investigation findings (Who, What, Why, and How the event occurred)." This was followed by:
- "Video Footage review showed no self harm with the screw retrieved from the ceiling."
- "Violent BH patient recently transferred from [ED] to [BHU seclusion room], hit the ceiling of [BHU seclusion room] with [their] head, and a 1-inch sheet metal screw popped out of the ceiling onto the floor, and patient used the screw to etch the domes of both room cameras. After patient complied and dropped the screw onto the floor, Security breeched the room, and gained control of the patient."
- "While the patient was secluded [they] ... also kicked at the door and the observation window ... Code Gray was called ... many Security Officers [were] present ... a plan was developed ... I requ

Based on interview, review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff education/training materials, and review of other documentation, it was determined that the hospital failed to ensure patients' rights were recognized, protected and promoted as follows:
* Staff were not trained and did not demonstrate competency in the use of first aid techniques that may be needed during patient restraint and seclusion.

Findings include:

1. Staff orientation and annual training materials provided were reviewed and did not include staff training and competencies that addressed restraint related first aid techniques. Examples included:
* The "Providence Health & Services PMAB Practical Learning Curriculum" hands on skills training dated "Revised 09_2022" was reviewed and reflected no information regarding restraint related first aid techniques training and competencies.
* Review of the MHA "Seclusion & Restraint (SR) Checklist" dated "Revised 11/10/2021" included no information regarding restraint related first aid techniques training and competencies.
* Review of MHA orientation training materials included a document titled "Thinking Critically About Restraints," dated "August 2019." It reflected "Risks associated with restraint use ... death from strangulation, asphyxiation, or trauma ... increased risk for falls ... bruising, swelling, redness, skin tears, scrapes ..." The document did not include information regarding restraint related first aid techniques training and competencies.

2. Review of staff education/training records with the ND, HRG and other hospital staff on 12/06/2023 beginning at 1340 reflected they contained no staff training and competencies for first aid techniques related to patients who were restrained or secluded, including appropriate first aid required if a restrained or secluded patient was in distress or injured for the following employees:
Employee 1, MHA with hire date 02/10/2014
Employee 2, MHA with hire date 12/06/1994
Employee 3, CNA/MHA with hire date 12/02/2019
Employee 4, RN with hire date 06/10/2019
Employee 5, MHA with hire date 03/21/2022
Employee 6, RN with hire date 03/13/2023
Employee 7, RN with hire date 03/28/2022
Employee 8, RN with hire date 03/27/2023

3. During an interview with the ANM on 12/06/2023 at the time of the staff education/training records review in finding 2, the ANM stated Employees 1, 2, 3, 4, 5, 6, 7 and 8 participated in restraint and seclusion activities.

4. In an email from EDO dated 12/20/2023 at 1227, they confirmed the lack of employee first aid training in findings 1 and 2.

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to hospital patients.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to findings cited at Tag A700 under CFR 482.41 - CoP: Physical Environment.

Based on interview, medical record and incident documentation for 4 of 4 patients admitted to the inpatient BHU reviewed for provision of nursing services (Patients 3, 4, 10 and 13), review of environmental rounds documentation, review of P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN supervised and evaluated patients to ensure the provision of safe and appropriate care in accordance with hospital policies and procedures including:
* Regarding Patient 13, the hospital failed to ensure the RN evaluated and supervised the patient's care. The patient, who was at risk for suicide and experiencing increased suicide statements, accessed a sheet and used it to commit suicide by asphyxiation. In addition, the hospital failed to ensure the RN notified the charge nurse and physician regarding Patient 13's increased suicidal statements.
* Regarding Patient 10, the hospital failed to ensure the RN assessed the patient for injuries after the patient was found with a sheet or blanket around their neck and self harming with a fork.
* Patient 4, who was admitted with SI and was isolating in their room, was found holding a sheet knotted into a noose, and the hospital failed to ensure the RN assigned and ensured environmental rounds, intended to identify unsafe items, were completed.
* Regarding Patient 3, the hospital failed to ensure the RN evaluated the patient for injuries after they fell and hit their head, including head and neurological assessment.
* Environmental rounds were not completed and documented in accordance with hospital P&Ps.
* CARES rounds were not complete and documented in accordance with hospital P&Ps.

Findings include:

1. Refer to the findings cited at Tag A144 regarding the hospital's failure to ensure the RN evaluated, supervised and prevented a patient from using a bed sheet to commit suicide by asphyxiation; and failure to ensure the RN notified the charge nurse and physician related to the patient's increased suicidal statements.

2. Refer to the findings cited at Tag A145 regarding the hospital's failure to ensure the RN evaluated patients after they engaged in self harm behaviors.

3. Refer to the findings cited at Tag A145 regarding the hospital's failure to ensure the RN appropriately evaluated patients after they fell.

4. Refer to the findings cited at Tags A144 and A145 regarding the hospital's failure to ensure RN assigned and ensured environmental rounds and CARES rounds were complete and documented in accordance with hospital P&Ps.

Based on interview, medical record and incident documentation for 2 of 2 patients reviewed for nursing care plan development (Patients 2 and 13), it was determined the hospital failed to ensure the RN developed and kept current a nursing care plan based on an assessment of the patient's individualized needs related to bowel incontinence and suicide risk.

Findings include:

1. Refer to Tag A144 related to the hospital's failure to ensure the RN developed and kept current Patient 2's care plan related to the patient's bowel incontinence.

2. Refer to Tag A144 related to the hospital's failure to ensure the RN developed and kept current Patient 13's care plan related to the patient's suicide risk.

3. The P&P titled "Adult and Pediatric Psychiatry Universal Assessment, Care Planning, and Discharge" dated last revised "12/2017" reflected:
* The nursing care shall be the responsibility of a registered nurse (RN)."
* "Plan of Care: ... Document goal outcome summary that evaluates the patient's progress toward goals once a shift ... with significant change in condition ... Update the CPG, goals, and interventions so they reflect the patient's current condition and needs."
* "Assess the C-SSRS Screening each shift or on assumption of care and make changes to precaution levels and individualized plan of care as appropriate."

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 4 of 6 patients who received inpatient BHU services (Patients 4, 7, 10 and 13), review of incident documentation for 4 of 14 patients involved in incidents on the inpatient BHU (Patients 4, 7, 10 and 13), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure patients received care in a safe physical environment as follows:
* The hospital failed to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items, and areas. Environmental risks had not been identified and/or mitigated and created the risk for self-harm.
* Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to asphyxiate themselves and died. Those conditions resulted in actual harm for Patient 13 and risk for serious harm or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under this CoP at Tag A701, CFR 482.41(a) - Standard: Buildings. Those findings reflect the hospital's failure to ensure care in a safe physical environment and represented an IJ situation.

2. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Care in a Safe Setting regarding Patient 13.

3. Refer to findings cited at Tag A145, CFR 482.13(c)(3) - Standard: Free From Abuse/harassment regarding Patients 4, 7 and 10.

44104

Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 4 of 6 patients who received inpatient BHU services (Patients 4, 7, 10 and 13), review of incident documentation for 4 of 14 patients involved in incidents on the inpatient BHU (Patients 4, 7, 10 and 13), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure patients received care in a safe physical environment as follows:
* The hospital failed to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items, and areas. Environmental risks had not been identified and/or mitigated and created the risk for self-harm. Those included but were not limited to gaps inside closets, holes in underside of bathroom sinks, entry doors to patient rooms, wall mounted cameras, unsecured platform beds, and patient bathroom door (hinges).
* Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to asphyxiate themselves and died. Those conditions resulted in actual harm for Patient 13 and risk for serious harm or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

Findings include:

Regarding BHU P&Ps:

1.a. The policy titled "Use of Routine & Special Observation for Patient Safety" dated last approved "05/2023" was reviewed and reflected:
* Under "General Requirements", 3.d. was written, "Staff assigned responsibility for conducting routine or special observations are to ... Routinely assess environment for potential risk factors impacting safety ..."
* Under "General Requirements", 4. was written, "Staff assigned routine or special observations are responsible for the complete documentation of each check. Q15 safety checks will be documented on 'Patient Safety Check' Log. Constant Observation (1:1) will be documented on the 'Constant Observation Log' form. All entries must reflect accurate time, location of patient, and staff initials."
* Under "E. Quality Monitoring" was written, "Charge nurses will have the responsibility to ensure that systems are in place to facilitate compliance to this policy. Periodic visual inspection of staff performance and documentation will be conducted during worked shifts ... Audits of required documentation and staff implementation of Observation practices will be conducted as needed, but at a minimum of twice per year ... Nurse Manager will ensure that the responsibilities and duties associated with this policy, process for observation at different levels, training needs and record keeping are maintained ... Q15 safety logs are part of the medical record ... Patient specific behavioral health observation logs will be scanned into the patient chart upon discharge."
The policy lacked a description of where the routine BH Shift Environmental Rounds, conducted twice daily, were to be documented. The policy lacked a plan to monitor and ensure that routine BH Shift Environmental Rounds were conducted in accordance with unit practice and expectations.

1.b. The policy titled "Searches of Patient Belongings Environment," dated last approved "10/21" was reviewed and reflected:
* Under "Definitions ... Routine ..." was written, "Routine searches include assessments of the environment for safety hazards and identification of unsafe items potentially brought onto unit." The policy lacked guidance on when or how often to conduct routine BH Shift Environmental Rounds rounds in accordance with unit practice and expectations.

1.c. The policy titled "Adult and Pediatric Psychiatry Universal Assessment, Care Planning, and Discharge" dated last approved "03/2023" was reviewed and reflected:
* Under "On Assumption of Care" was written, "Ensure environmental safety. (See addendum A) ... Perform and document purposeful rounds to ensure patient safety is maintained. (See addendum H)."
* Under "Other Safety and Essential Interventions" was written, "Cares Rounding designed for inpatient adult psychiatry is available in Addendum H." Refer to Tag A144 regarding "Purposeful Rounding" and CARES rounding.

1.d. An undated document titled "Standard Work Document ... OPH IP BH Day Charge RN Workflow" Version 1.0 was reviewed and reflected:
* Under "Standard Work Overview ... Desired Outcome 100% compliance"
* Under "Standard Work Steps ... Start of Shift ... Update current assignment sheet ... Notes ... Ensure that Environmental Rounds are assigned ... Check with MHA's [sic] to be sure they have the resources to perform their duties"

1.e. An undated document titled "Standard Work Document ... OPH IP BH Evening Charge RN Workflow" Version 1.0 was reviewed and reflected:
* Under "Standard Work Overview ... Desired Outcome 100% compliance"
* Under "Standard Work Steps ...Start of Shift ... Update current assignment sheet ... Notes ... Ensure that Environmental Rounds are assigned ... Check with MHA's [sic] to be sure they have the resources to perform their duties"

1.f. An undated document titled "Standard Work Document ... OPH IP BH MHA NOC SW" Version 1.0 was reviewed and reflected:
* The document listed "Standard Work Steps" that included but was not limited to the following MHA duties: "Milieu Management ... Conduct Q15 minute safety checks ... Participate in 1:1 observation care ... Assist with de-escalating agitated and combative patients ... Clean showers ... Observe mealtime ... Answer patient call lights ..."
The document did not list routine BH Shift Environmental Rounds rounds as one of the "Standard Work Steps".

1.g. An undated document titled "Standard Work Document ... OPH IP BH Safety Guidelines_Inpatient Behavioral Health Units SW" was reviewed and reflected:
* Under "Standard Work Steps" was written, "Patient Rounding When making rounds for patient monitoring, actively assess physical environments for all potential hazards and risks ... (Reference Policy ... Use of Routine & Special Observations for Patient Safety)".
The document did not specifically address routine BH Shift Environmental Rounds.

Regarding BHU physical environment risk assessment:

2. The following documents were provided in response to a request for the hospital's BHU environmental risk assessment and mitigation strategies:
* "PPMC_Mental Health Environment of Care Checklist_5thfloor 08.24" which had been conducted prior to the incident involving Patient 13 which occurred on 11/17/2023, and
* "PPMC_Mental Health Environment of Care Checklist_5thfloor 11.22.2023" which had been conducted after the 11/17/2023 incident involving Patient 13.
Potential risks which were not included on the hospital's Environmental Risk Assessment tools, or which were not mitigated at the time of the survey are noted in finding 3.a. below.

3.a. Tours and direct observations of the BHU were conducted with the ANM, EDO and DA/R on 11/28/2023 beginning at 1535 and 11/29/2023 beginning at 1525. Unsafe areas, items, ligature risks, and other safety risks were observed throughout the unit which created the likelihood for patient harm and were either not identified on the hospital's 8/24/2023 and 11/22/2023 Environmental Risk Assessment tools, or risks from these items were not mitigated prior to the date of this survey. Unidentified and unmitigated risks included, but were not limited to the following:

* On 11/28/2023 at 1542, in room 5L14, surveyors observed a sink in the patient's bathroom with loopable holes approximately 1-1.5 inches in diameter, located on the underside of the sink basin and approximately 30 inches from the floor. There were three holes on each side of the basin for a total of six holes. Surveyors were able to thread a phone charging cable on the left side of the sink from the first hole through to the second hole creating a downward ligature point. The patient bathroom was not in line of sight of the camera for patient privacy.

This loopable area and ligature risk had not been identified on either of the hospital's Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023.

* On 11/28/2023 at 1542, in room 5L14, the same bathroom sink was observed with a curved faucet. Surveyors were able to loop a pair of unit-issued scrub pants over the curved faucet and put weight on it without it slipping off, creating a downward ligature risk.

Although "sinks" and "plumbing" had been identified as a possible ligature risk, the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools noted that the mitigation of risk in patient bathrooms had been "Met".

* On 11/28/2023 at 1542, in room 5L14, a single shelf within the patient's closet was not set flush with the cabinetry and gaps approximately 1/4 inch wide on both right and left sides of the shelf were observed. The shelf was approximately 46 inches from the floor. Surveyors were able to slip a sheet through these gaps, creating an anchor point and potential ligature risk.

The closet gaps had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools with a notation that risk mitigation was "Not Met", and 3 mitigation strategies were listed: "... 15 Minute Safety Checks ... Line of Sight of Camera ... Facilities Work Order". However, risk mitigation strategies listed did not fully mitigate the ligature risk in all patient rooms where the risk existed as some closets were not in the line of sight of the camera. This was confirmed by live video surveillance with staff present during tour of the BHU.

* On 11/28/2023 at ~1555, in room 5L12, a wall-mounted camera was observed approximately 6 inches from the ceiling. The camera was not flush mounted to the wall nor was it slanted, creating an anchor point. Surveyors were able to loop a pillowcase around the camera housing and put enough weight on it to demonstrate a potential ligature risk.

This ligature risk had not been identified on either of the hospital's Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023.

* On 11/28/2023 at 1600, the hallway door to room 5L14 was observed to have a small gap between the top of the door and the door frame. Surveyors verified that a bed sheet could be draped over the top of the door and the door shut creating an anchor point and ligature risk if one end of the sheet was knotted. The top right corner of the door was not visible by either of the cameras in the room or in the hallway. This was confirmed by live video surveillance with staff present during tour of the BHU.

Camera "blind spots" had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, and noted as "Partially Met". Mitigation notes on both the Environmental Risk Assessment tools reflected, "Some identified blind spots from camera in hall and alcoves. All identified blind spots are added to the 15 min check round." Under "Mitigation Plan" was written "... 15 minute Safety Checks". However, the top of doors or alcoves leading into patient rooms were not listed on the "15 min check" form and the risk had not been mitigated at the time of the survey.

* On 11/28/2023 at 1601, an "Exit" sign was observed approximately 4 feet from room 5L14. The sign was not flush mounted to the ceiling creating loopable areas.

Exit sign gaps had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools and noted as "Partially Met". Mitigation notes on both the Environmental Risk Assessment tools reflected, "... Line of sight ... 15 min checks ... facilities work order ... line of sight of care givers". However, 5L14, and this exit sign was located on L hall which is not in the line of sight of the nursing station, or caregivers except when caregivers were in L hall. The risk had not been fully mitigated at the time of the survey.

* On 11/28/2023 at 1601, a fire alarm warning light was observed approximately 6 feet across from room 5L14. The fire alarm warning light was mounted at a right angle to the wall creating a loopable anchor point.

The fire alarm warning light had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools and noted as "Partially Met". Mitigation notes on both the Environmental Risk Assessment tools reflected, "... Line of sight ... 15 min checks ... facilities work order ... line of sight of care givers". However, 5L14, and this alarm warning light was located on L hall which is not in the line of sight of the nursing station, or caregivers except when they were in the hall. The risk had not been fully mitigated at the time of the survey.

* On 11/28/2023 at 1609, in room 5L10, surveyors observed another sink in the patient bathroom with loopable holes approximately 1-1.5 inches in diameter and located on the underside of the sink basin. There were three holes on each side of the basin for a total of six holes.

The patient bathroom was not in line of sight of the camera for patient privacy. This loopable area and potential ligature risk had not been identified on either of the hospital's Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023.

* On 11/28/2023 at 1611, in room 5L11, a dresser with three drawers was observed next to the patient closet. The top drawer was approximately 24 inches from the floor and had a front drawer facing that created a lip that prevented looped items from sliding off the end of the drawer and provided a secure anchor point. Surveyors were able to loop a sheet and exert enough weight on this anchor point to demonstrate a ligature risk without the dresser toppling over.

The drawers as anchor points had not been identified on the hospital's Environmental Risk Assessment tool dated 8/24/2023.

* On 11/28/2023 at 1615, in room 5L09, a single shelf within the patient's closet was not set flush with the cabinetry and gaps approximately 1/4 inch wide on both right and left sides of the shelf were observed. The shelf was approximately 46 inches from the floor. Surveyors were able to slip a sheet through these gaps, creating an anchor point for a knotted sheet.

The closet gaps had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, risk mitigation was noted to be "Not Met", and 3 mitigation strategies were listed. However, risk mitigation strategies listed did not fully mitigate the ligature risk in all patient rooms where the risk existed at the time of the survey as this closet was not in the line of sight of the camera. This was confirmed by live video surveillance with staff present during tour of the BHU.

* On 11/28/2023 at 1617, in room 5L09, surveyors observed a slanted bathroom door with a continuous hinge. Surveyors successfully looped a sheet around the top of the hinge and one surveyor was able to hang from the door hinge.

Although "Interior Bathroom Doors" under the category titled "Bathrooms" had been identified on the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, the tools noted that risk mitigation had been "Met". On the same Environmental Risk Assessment tools, under the category of "Hinges", the ligature risk mitigation for hinges had also been noted as "Met" for all doors except those located in the "Sensory room" where the tools noted "Partially Met", and that a process was being developed to have hinges checked on a routine basis. Under a third category titled "Interior Doors that do not need to limit the transfer of smoke", the hospital's 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools also noted that ligature risk mitigation had been "Met" by slanted doors. Risk mitigation strategies for this ligature risk were not fully implemented at the time of the survey.

* On 11/28/2023 at 1627, in room 5L07, two wood-framed platform beds were observed. The platform beds were low to the ground but were not secured to the floor or the wall. One surveyor was able to easily lift the wooden bed without assistance and turn the bed on its side creating a long, flat surface approximately seventeen inches wide, eighty inches in length and approximately three feet high.

An unmitigated risk existed for self-harm from jumping or falling from these pieces of unsecured furniture when turned on their side. Further, the wooden bed frame had no enclosed base, which created an empty, open area on the underside of the bed large enough for a patient to fully lie down and hide themselves, or within which to hide contraband. An additional potential risk existed for the two beds to be used in combination to create a barricade due to their size, weight and maneuverability. These risks had not been identified or evaluated on either of the hospital's Environmental Risk Assessment tools dated 08/24/23 and 11/22/2023. The tools listed this type of furniture in three categories: "Furniture - general considerations", "Furniture in private areas ... bedrooms ..." and "Platform Beds". Further, the Environmental Risk Assessment tools noted that risk mitigation had been "Met" in all three areas. The risk assessment lacked additional comments regarding any related self-harm risks associated with this furniture. Specifically, there were no comments regarding, "jumping or falling", "hiding of contraband or patients", or "anti-barricade" mitigation strategies related to these beds.

* On 11/28/2023 at 1604, a locked room identified as the patient belongings/laundry room and located directly across from 5L14 was observed to have a secondary door to a storage area that contained cleaning supplies. The hallway door entering the laundry room was locked, however, the entry door to the cleaning supply closet was propped open, unlocked, and a sign was posted on the door reading "5L/5E Hazard Spill Kit".

Although "Chemicals ... Utility Rooms" had been identified on the hospital's 08/24/2023 Environmental Risk Assessment, the risk mitigation was described as "Met" and no other comments by the facility other than the standardized template language of "locked" and "supervision" were noted. The identified risk of chemicals in the "Laundry room" had mitigation notes which stated, "NA" and "No patients use the laundry room." However, a review of the MHA Orientation Packet provided by the hospital, reflected a 1-page document titled "Behavioral Health Unit Standard Operating Procedure: Staff responsibility for the laundry room and washing machine ..." which provided guidance to staff on the supervision of patients when using the laundry room. It is unclear whether patients were ever "encouraged to do their own laundry to help maximize their independence with ADL's [sic]' as stated in an MHA Orientation Packet in finding 3.c. or whether the laundry room was never used by patients as indicated in an email from the EDO on 12/13/2023 at 1644, also in finding 3.c.

* On 12/18/2023 at 1353, an upright refrigerator/freezer with two vertical loopable handles was observed in the main kitchen area of the BH unit.

These two anchor points had not been identified on either of the hospital's Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023.

3.b. During interview on 11/29/2023 at 1230 the ANM stated none of the patient room bathrooms have a camera inside them. Therefore, those bathrooms would not be visible from camera views in patient rooms, particularly when bathroom privacy curtains and doors were closed.

3.c. During review of an MHA orientation training/education packet, an undated 1-page document titled "Behavioral Health Unit Standard Operating Procedure: Staff responsibility for the laundry room and washing machine ..." was reviewed. It reflected:
- "The following rules apply for patient use of the washer/dryer: Patient must be supervised by nursing staff. If helping a patient do their laundry on L side make sure the door is open, that you are wearing a vocera and that you have told a co-worker what you are doing. This is an isolated area and poses foreseeable risks ... Patients should be encouraged to do their own laundry to help maximize their independence with ADL's [sic]." The document contradicts information provided by the hospital regarding the use of the laundry room by patients and the risk mitigation strategies as noted on the Environmental Risk Assessment tools in finding 4.a. In an interview conducted with the EDO on 12/13/2023 at 1644 via email, the EDO wrote: "The laundry room on 5L in the L hallway is not accessible by patients, and unit leadership confirmed that patients are never in this space. This is the most current version of the MHA orientation packet."

Regarding BH Shift Environmental Rounds:

4.a. On 12/01/2023, at 1516, documentation of the unit's routine, twice daily BH Shift Environmental Rounds, beginning 01/01/2023 - 11/28/2023, was requested. The hospital provided 105 forms titled "Behavioral Health Shift Environmental Rounds" which contained the following instructions, "The below form is completed at the start of each shift (0700 & 1900) and placed in the Environmental Rounds binder kept in the nurses [sic] station. Documentation of this rounding form is to be completed by two staff, both staff need to print name, initial and put time this was completed." The form contained a place to write the unit and the date, and three columns, titled, "Area ... 0700 Initials/Time ... 1900 Initials/Time". Ten areas of observation were listed and included a corresponding "box" for staff to write "Initials/Time". The bottom of the form contained two signature lines for four staff to sign. The form version was undated. Of the forms provided, the majority were incomplete, instructions printed on the form were not followed, and rounds were either missed or not documented. Examples include but are not limited to:

* No forms were provided for the month of January 2023.

* A form dated "2/3/23" reflected two staff initials in seven of ten boxes for the "0700" column. Three boxes contained only one staff's initials in the areas of "ALL patient rooms and bathrooms visualized for safety concerns ... Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...". The "1900" column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines.

* A form dated "2/25/23" reflected two staff initials in ten of ten boxes for the "0700" column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. Two MHA names and initials were written on the signature lines.

* A form dated "2/26/23" reflected two staff initials in seven of ten boxes for the "0700" column. Three boxes contained only one staff's initials in the areas of "Group room/Sensory room/Day room/Interview rooms ... Refrigerators locked ... Hover Jack charging ...". There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. Two MHA names and initials were written on the signature lines.

* A form dated "3/01/23" reflected the initials of one staff in ten of ten boxes for the "0700" column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. The first signature line contained two MHA staff initials which appeared to be identical, with only one printed first name.

* A form dated "3/02/23" reflected the initials of one staff in ten of ten boxes for the "0700" column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. One MHA name and initials were written on the signature lines.

* A form dated "3/4/23" reflected two staff initials in eight of ten boxes for the "0700" column. Two boxes contained only one staff's initials in the areas of "Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...". The "1900" column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines.

* A form dated "3/5/23" reflected two staff initials in eight of ten boxes for the "0700" column. Two boxes contained only one staff's initials in the areas of "Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...". The "1900" column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines along with one CNA name and initials.

* A form dated "3/16/23" reflected ten of ten boxes for the "0700" column lacked staff initials and times. The "1900" column reflected the initials of one staff in ten of ten boxes. There were no times written next to the initials per the form instructions. One name and initials were written on the signature lines. There was no staff title.

* A form dated "4/21/23" reflected the initials of one staff in ten of ten boxes for the "0700" column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. One MHA name and initials were written on the signature lines.

* No forms were provided for the months of May, June, July or August 2023.

* A form dated "9/28/23" reflected the initials of one staff in eight of ten boxes for the "0700" column. Two boxes in the areas of "Laundry room (E & L halls) doors are locked ... Group room/Sensory room/Day room/Interview rooms ..." lacked staff initials and times. The "1900" column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. One MHA name and initials were written on the signature lines.

* A form dated "10/13/23" reflected ten of ten boxes for the "0700" column lacked staff initials and times. The initials of one staff were written in nine of ten boxes for the "1900" column. The area, "ALL patient rooms and bathrooms visualized for safety concerns ..." lacked staff initials and a time. There were no times written next to the initials in the other nine boxes per the form instructions. One MHA name and initials were written on the signature lines.

* A form dated "11/17/23", the date of the incident, reflected the initials of one staff in ten of ten boxes for the "0700" column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the "1900" column lacked staff initials and times. One MHA name and initials were written on the signature lines.

Additionally, of the estimated 663 BH Shift Environmental Rounds required to be completed beginning day shift, 01/01/2023 through day shift, 11/28/2023, the hospital provided 125 documented BH Shift Environmental Rounds, for an averaged completion rate of 19%, well below the 100% compliance rate described in the "Standard Work Document[s]" above.

4.b. During an interview with the EDO via email on 12/13/2023 at 1640, the EDO confirmed that the hospital had provided all documentation of shift environmental rounds. Additionally, they provided the information on whether two staff were required to complete the rounds per the form instructions and staff training materials, times when the rounds occurred, and how often shift environmental rounds were required.
* The EDO wrote: "EOC shift rounds - overall:
a. Unable to confirm, leadership review revealed a mix of completed not documented and not completed.
b. Unable to confirm second set of initials, no video footage is unavailable [sic] due to storage limitations. The practice prior to new process implementation was to have two caregivers perform, however, it was discovered this created significant challenges to operationalize and was not required by policy, thus potentially creating gaps.
c. Unable to confirm time performed if not documented.
d. EOC rounds are expected each shift, unable to confirm completion if not documented."