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Based on document reviews and interviews, it was determined that the Condition of Participation ("CoP") for Governing Body was not met as evidenced by the Governing Body's failure to provide oversight of the hospital. This failure was evidenced by the following: the failure to ensure the entire environment, including the passageway into the kitchen, was thoroughly assessed for patient access and safety; failure to re-evaluate the kitchen/cafeteria area after one (1) patient accessed the area which enabled a second patient to access the kitchen and commit suicide; and failure to ensure adverse events were identified, evaluated, and used as opportunities to improve patient safety.

Findings:

The Governing Body has failed to provide oversight of the hospital as evidenced by the following:


1. Condition: §482.13 CoP: Patient Rights also known as A-0115 - Based on document review and interviews, it was determined that the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure a patient's right to receive care in a safe setting for two (2) of eleven (11) sampled patients, who were able to access the kitchen area unimpeded. One patient (Patient #11) was able to be redirected away from the kitchen, while the other patient (Patient #1) obtained a knife in the kitchen and committed suicide. See A-0115 for details.

2. Standard: §482.13(c)(2) Patient Rights also known as A-0144 - Based on record reviews and interviews, the hospital failed to ensure all patients received care in a safe setting. This failure was evidenced by the following: the hospital conducted internal safety risk assessments that failed to identify safety issues related to the passageway into the kitchen area; Patient #11 accessed the kitchen, a non-patient area, on 2/24/2022; the hospital failed to re-evaluate patient's accessibility to enter the kitchen after 2/24/2022; and on 6/12/2022 Patient #11 accessed the kitchen, obtained a knife, and self-inflicted fatal knife wounds. The hospital took action to prevent access to the kitchen after the 6/12/2022 incident.

3. Condition: §482.21 Quality Assessment and Performance Improvement Program ("QAPI") also known as A-0263 Based on document review and interviews, it was determined the Condition of Participation for Quality Assessment and Performance Improvement ("QAPI") was not met as evidenced by the hospital's failure to ensure its QAPI Program had tracked an adverse patient event, analyzed the causes and implemented preventive actions, and mechanisms that included feedback and learning throughout the hospital for one (1) of eleven (11) patients reviewed (Patient #11). See A-0263 for details.

4. Standard §482.21(a), (c)(2), (e)(3) Patient Safety also known as A-0286 - Based on record reviews and interviews, the hospital failed to ensure their incident reporting system was effective in identifying adverse incidents so the incidents can be tracked, analyzed, and preventative measures can be implemented and feedback and opportunities for learning can be provided throughout the hospital for one (1) of one (1) adverse event identified but not reported (Patient #11). This failure resulted in a second patient (Patient #1) entering a non-patient area (kitchen) where items were accessible for the patient to self-inflict fatal knife wounds.


The cumulative effect of these deficient practices resulted in noncompliance with this CoP.

Based on document review and interviews, it was determined that the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure a patient's right to receive care in a safe setting for two (2) of eleven (11) sampled patients, who were able to access the kitchen area unimpeded. One patient (Patient #11) was able to be redirected away from the kitchen, while the other patient (Patient #1) obtained a knife in the kitchen and committed suicide.


Finding:

Standard: §482.13(c)(2) Patient Rights: Care in a Safe Setting also known as A-0144 - Based on document review and interviews, the hospital failed to ensure a patient's right to receive care in a safe setting for two (2) of eleven (11) sampled patients, who were able to access the kitchen area unimpeded. One patient (Patient #11) was able to be redirected away from the kitchen, while the other patient (Patient #1) obtained a knife in the kitchen and committed suicide. See A-0144 for details.


The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on record reviews and interviews, the hospital failed to ensure all patients received care in a safe setting. This failure was evidenced by the following: the hospital conducted internal safety risk assessments that failed to identify safety issues related to the passageway into the kitchen area; Patient #11 accessed the kitchen, a non-patient area, on 2/24/2022; the hospital failed to re-evaluate patient's accessibility to enter the kitchen after 2/24/2022; and on 6/12/2022 Patient #11 accessed the kitchen, obtained a knife, and self-inflicted fatal knife wounds. The hospital took action to prevent access to the kitchen after the 6/12/2022 incident

Findings:

On 6/15/2022, an on-site investigation was initiated for the following incident that was reported to the State Agency by Spring Harbor Hospital and Adult Protective Services: On 6/12/2022 at approximately 5:39 PM, Patient #1 was in the kitchen area where he/she selected a tray of food then spontaneously slammed the tray down and ran into the kitchen. Once in the kitchen, he/she grabbed several random items including a knife. He/she cut his/her neck which resulted in the need for hospital staff to initiate cardiopulmonary resuscitation and calling 911. Emergency medical technicians arrived on the scene and continued resuscitation efforts. Resuscitation efforts were unsuccessful, and the patient died at the psychiatric hospital from the self-inflicted wounds.

The hospital provided the surveyors with the "2019 Proactive Risk Assessment", "2020 Proactive Risk Assessment", and the "2021 Proactive Risk Assessment". These three (3) internal assessments (i.e.: conducted by the hospital, not an outside consultant) failed to identify that patients could access the kitchen from the cafeteria area where items were available that could be used to harm self or others.

On 6/15/2022 between 3:00 PM and 3:30 PM, Behavioral Technician #2 was interviewed about the incident involving Patient #1. During this interview, she stated that she had heard there was an incident, approximately two (2) months prior, where another patient, Patient #11, had ran into the kitchen.

On 6/17/2022 between 12:00 PM and 12:15 PM, the Social Worker was interviewed. She stated the following:
· she was present when Patient #11 ran into the kitchen;
· the patient entered the kitchen through the entrance at the end of the area that the patients get their food;
· the patient was able to get at least ten (10) feet into the kitchen before staff were able to redirect him/her from the
area;
· this event occurred back in February 2022;
· the event had been discussed at the team treatment team meeting the next morning; and
· she didn't think an incident report had been completed.

Patient #11's clinical record was reviewed and documentation, dated 2/25/2022, confirmed that on 2/24/2022 this patient ran into the kitchen.

Patient #1's clinical record was reviewed. A Discharge Summary Note, signed by Brendan Kirby, MD, dated 06/13/2022 at 1:38 PM, stated the following: "At around 1800 code gray was called on the intercom, which was immediately changed to a CODE BLUE, over in the kitchen. Staff rushed over to the kitchen where [Patient #1] was lying on the floor next to about a puddle of blood after stabbing self in the neck with a kitchen knife. Per nursing report and staff report patient was reclusive and isolated for most of the shift until [he/she] went over to the kitchen where [he/she] selected a tray of food, upon receiving [his/her] tray [he/she] spontaneously slammed a tray and proceeded to run into the kitchen where [he/she] grabbed several random items in the kitchen until [he/she] found a knife which [he/she] utilized to commit suicide."

On 6/16/2022 between 2:30 PM and 2:45 PM, Behavioral Technician #1, who was present during the incident involving Patient #1 on 6/12/2022, was interviewed. She described in detail the incident of Patient #1 self-inflicting the fatal wounds and her account was consistent in what was reported to the State Agency and the documentation in the patient's clinical record.

On 2/24/2022, Patient #11 entered the kitchen. There was no evidence provided to surveyors that the hospital had evaluated the environment in the cafeteria/kitchen area in relation to safety after this 2/24/2022 incident; therefore, this area, continued to be accessible to patients. On 6/12/2022, Patient #11 entered the kitchen, obtained a knife, and self-inflicted fatal knife wounds. The hospital acted in relation to the accessibility of this non-patient area only after the 6/12/2022 fatal incident. This action consisted of installing, on 6/13/2022, a temporary locked door in the entrance of the kitchen that both patients entered and locking other unlocked kitchen doors that they identified that opened into the hallway.

Based on document review and interviews, the Condition of Participation ("CoP") for Quality Assessment and Performance Improvement was not met as evidenced by the hospital's failure to ensure that its Quality Assurance Performance Improvement Program ("QAPI") had tracked an adverse patient event, analyzed the causes and implemented preventive actions, and mechanisms that included feedback and learning throughout the hospital for one (1) of one (1) adverse event. (2/24/2022).

Finding:

Standard §482.21(a)(1) and 482.21(a)(2) - Program Scope, 482.21(c)(2) - Program Activities and 482.21(e)(3) - Executive Responsibilities - Based on record reviews and interviews, the hospital failed to ensure there was a reporting system to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that included feedback and learning throughout the hospital. See A-0286 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this CoP.

Based on record reviews and interviews, the hospital failed to ensure their incident reporting system was effective in identifying adverse incidents so the incidents can be tracked, analyzed, and preventative measures can be implemented and feedback and opportunities for learning can be provided throughout the hospital for one (1) of one (1) adverse event identified but not reported (Patient #11). This failure resulted in a second patient (Patient #1) entering a non-patient area (kitchen) where items were accessible for the patient to self-inflict fatal knife wounds.

Finding:

On 6/15/2022, an on-site investigation was initiated for the following incident that was reported to the State Agency by Spring Harbor Hospital and Adult Protective Services: On 6/12/2022 at approximately 5:39 PM, Patient #1 was in the kitchen area where he/she selected a tray of food then spontaneously slammed the tray down and ran into the kitchen. Once in the kitchen, he/she grabbed several random items including a knife. He/she cut his/her neck which resulted in the need for hospital staff to initiate cardiopulmonary resuscitation and calling 911. Emergency medical technicians arrived on the scene and continued resuscitation efforts. Resuscitation efforts were unsuccessful, and the patient died at the psychiatric hospital from the self-inflicted wounds.

On 6/15/2022 between 3:00 PM and 3:30 PM, Behavioral Technician #2 was interviewed about the incident involving Patient #1. During this interview, she stated that she had heard there was an incident, approximately two (2) months prior, where another patient, Patient #11, had ran into the kitchen. She heard about this through hospital staff talking about the incident but did not witness same.

On 6/17/2022 between 12:00 PM and 12:15 PM, the Social Worker was interviewed. She stated the following:
· she was present when Patient #11 ran into the kitchen;
· the patient entered the kitchen through the entrance at the end of the area that the patients get their food;
· the patient was able to get at least ten (10) feet into the kitchen before staff were able to redirect him/her from the
area;
· this event occurred back in February 2022;
· the event had been discussed at the team treatment team meeting the next morning; and
· she didn't think an incident report had been completed.

Patient #11's clinical record was reviewed and documentation, dated 2/25/2022, confirmed that on 2/24/2022 this patient ran into the kitchen.

Patient #1's clinical record was reviewed. A Discharge Summary Note, signed by Brendan Kirby, MD, dated 06/13/2022 at 1:38 PM, stated the following: "At around 1800 code gray was called on the intercom, which was immediately changed to a CODE BLUE, over in the kitchen. Staff rushed over to the kitchen where [Patient #1] was lying on the floor next to about a puddle of blood after stabbing self in the neck with a kitchen knife. Per nursing report and staff report patient was reclusive and isolated for most of the shift until [he/she] went over to the kitchen where [he/she] selected a tray of food, upon receiving [his/her] tray [he/she] spontaneously slammed a tray and proceeded to run into the kitchen where [he/she] grabbed several random items in the kitchen until [he/she] found a knife which [he/she] utilized to commit suicide."

On 6/16/2022 between 2:30 PM and 2:45 PM, Behavioral Technician #1, who was present during the incident involving Patient #1 on 6/12/2022, was interviewed. She described in detail the incident of Patient #1 self-inflicting the fatal neck wounds and her account was consistent in what was reported to the State Agency and the documentation in the patient's clinical record.

A review of the hospital's "Incident Reporting" policy and procedure, last updated October 2021, was conducted. This policy and procedure stated, in part, "An electronic incident report should be entered into RL solutions [the Hospital's incident tracking system] for any unusual incident, accident, event or injury that occurs outside the scope of daily operations of Spring Harbor Hospital. Once identified, the event should be reported by the end of that shift. The incident reporting system is a Peer Review process which is used to identify and report occurrences which are not consistent with routine operations or routine patient care. Incident Report data is used to monitor outcomes and to proactively identify opportunities for improvement in processes or systems which may improve patient and staff safety."

On 06/15/2022 at 2:19 PM, Patient Relations Coordinator was interviewed. When asked if he was aware of any other patients, other than Patient #1, attempting to enter or entering the kitchen, he stated the current building opened in 2004 and, since the opening of the building, he was not aware of any issues involving inappropriate access to the kitchen from the food service area prior to this event of 6/12/2022.

On 6/16/2022 between 12:30 PM and 1:30 PM, the Vice President of Quality and Safety was interviewed. He stated the open passageway in the cafeteria leading to the kitchen area has never been a part of an incident report before, or an in-house annual risk assessment, or risk assessment done by an outside agency.

On 6/17/2022 at 9:36 AM, the Physical Plant Manager was interviewed. He stated there were no known previous incidents of patients or visitors going through the passageway into the kitchen.

On 6/17/2022 between 11:00 AM and 11:15 AM, the Accreditation Specialist was interviewed and was asked about an incident report involving Patient #11 running into the kitchen. She confirmed that no incident report had been completed and that an incident of a patient running into a non-patient area would be an unusual or unexpected event; therefore, an incident report should have been completed. During this interview, the surveyor also was shown all incident reports involving Patient #11 and confirmed no incident report had been completed for the 2/24/2022 incident.

Based upon the above information, the hospital's incident reporting system is utilized to identify opportunities to improve patient safety; therefore, this system failed, and the result was a patient's death from self-inflicted knife wounds. On 2/24/2022, Patient #11 accessed a non-patient area (the kitchen) that contained items that had the potential to be used to harm self or others. An incident report was not completed. There was no evidence provided to surveyors that the hospital had evaluated the environment in the cafeteria/kitchen area in relation to safety after the 2/24/2022 incident. This failure to evaluate the area after 2/24/2022 enabled Patient #1, on 6/12/2022, to access the kitchen and commit suicide. The hospital acted only after the 6/12/2022 fatal incident by installing, on 6/13/2022, a temporary lockable door in the entrance of the kitchen through which both patients accessed the kitchen. Additionally, the hospital locked other unlocked kitchen doors that they identified that opened into the hallway.