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Based on observation, staff interviews, medical record review, review of employee personnel files, and review of facility documents, it was determined the facility failed to ensure that at risk patients are cared for in a safe setting as evidenced by: utilizing smoking materials such as cigarette lighters in accordance with facility policy (A0144), identifying and mitigating environmental safety issues, including protruding screws and breakable windows (A0144), mitigating the ligature risk associated with sprinkler heads covered by escutcheon plates identified on the Environmental Risk Assessment (A0144), ensuring investigations and subsequent action plans are conducted for incidents regarding patient safety and security concerns (A0144), and ensuring all direct care staff receive Handle with Care training annually, in accordance with facility policy (A0144). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.

An Immediate Jeopardy (IJ) was identified on 05/25/23 at 1:30 PM. Staff #2 (CEO) was informed of the IJ and provided with the IJ template on 05/25/23 at 5:38 PM. On 05/26/23, the facility submitted an acceptable removal plan.

During the on-site visit on 05/26/23, it was determined the facility purchased long wand lighters and re-educated staff that all patient cigarettes will be lit by a staff member, as per the facility's "Smoking Policy." This was verified during the on-site visit through observation of smoke breaks, signed attestations of education, and staff interviews. It was determined the facility implemented the removal plan and the IJ was removed on 05/26/23 at 3:00 PM.

Cross Reference:
482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on observation, staff interviews, review of seven of 10 medical records (#4, #8, #10, #12, #13, #14, #15), review of seven of 15 employee personnel files (#6, #7, #9, #10, #14, #24, #25), and review of facility documents, it was determined the facility failed to ensure that: 1) smoking materials such as cigarette lighters, are utilized in accordance with facility policy; 2) environmental safety issues are identified and mitigated; 3) ligature risks identified on Environmental Risk Assessments are mitigated; 4) an investigation and subsequent action plan is conducted for incidents regarding patient safety and security concerns; 5) staff receive Handle With Care training annually, in accordance with facility policy.

Findings include:

1) Reference: Facility policy titled, "Smoking Policy" (last revised 12/2019) states, " ... Procedure ... 3. Where clinically approved, smoking materials will be managed and stored in designated safe areas and distributed by staff. Staff will light all patient cigarettes, and re-direct patients to dispose of cigarette butts in the designated receptacles."

During a tour of Unit TU5 on 5/25/23, the following safety issues were identified:

At 1:05 PM, the TU5 unit outdoor break was occurring in the Center Courtyard. A patient was observed walking across the courtyard and handing a lighter to Staff #35, a Mental Health Associate (MHA). Staff #35 then handed the lighter to another patient, who lit his/her cigarette and returned the lighter to Staff #35.

At 1:23 PM, the TU3 unit outdoor break was occurring in the Center Courtyard. Staff #8 (MHA) was sitting on a bench when a patient walked across the courtyard and handed Staff #8 a lighter. Staff #8 was observed handing the lighter to another patient, who lit his/her cigarette and then handed the lighter back to Staff #8.

During an interview at 2:53 PM, Staff #35 stated that he/she lights the cigarette for the patients. When made aware that he/she was observed handing the lighter to the patient, Staff #35 responded, "Sometimes patients can be difficult and we hand them the lighter. When patients come out for a smoke break late, we just yell 'who has the lighter' and provide them with the lighter. We make sure that we get the lighter back before going back inside." Staff #35 confirmed that the facility's policy is to light the cigarette for the patients.

During an interview at 2:08 PM, on the TU3 unit, Staff #8 stated that he/she lights the patient's cigarette for them. When made aware that he/she was observed handing the lighter to a patient, Staff #8 responded, "I'm going to be honest - I'm tired and I'm the only MHA on the unit and I just handed them the lighter."

Review of facility incident reports revealed that on 02/07/22, Patient #13 was able to obtain a lighter and set his/her mattress and blanket on fire in his/her room. It was unclear whether the lighter was obtained from the patient's belongings or taken during a smoke break.










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2) Reference: Facility policy titled "Environmental Rounds" (last revised 7/2020) states, " ... 2. An Environmental Tour Team will be utilized in conducting the tours and documentation of the inspections. ... b. The Team should consist of representatives from the following departments: i. Plant Operations ... ii. Infection Control/Risk Management ... iii. Environmental Services ... iv. Nursing (for clinical areas). 3. All identified discrepancies and issues will be documented on the form and submitted to the Safety Officer after completion. During the tour, if the charge nurse, department manager, or director is available, indicate the issues and show them where they are located. ... 9. The Safety Officer will continue to maintain the documentation of the environmental tour deficiencies. 10. The Safety Officer will trend and analyze the environmental tour inspections using Attachment B - Environmental Rounds Analysis Form and provide completion, data, and issues to the Environment of Care Committee on no less than a semi-annual basis."

During a facility tour on 05/16/23, in the presence of Staff #1 (COO) and Staff #2 (CEO), the following environmental safety issues were identified:

At 12:45 PM on Unit TU4, screws on the pillar located outside Room 245 were protruding from the pillar and not flush against the surface. The protruding screws were easily accessible to patients and could be removed. There was no evidence that the protruding screws were identified during monthly environment of care rounds.

Upon interview on 05/16/23 at 11:18 AM, Staff #1 stated, "The ICP [Infection Control Professional] and the DON [Director of Nursing] conduct weekly environmental rounds and sends an email to the Director of Plant Ops [Operations], who will schedule maintenance and handle any environmental issues. The Director of Plant Ops keeps a list of items that required maintenance."

On 05/17/23, review of a facility incident report dated 08/29/22 indicated Patient #10 (P10) broke a window on his/her unit and eloped. A request was made to Staff #1 and Staff #4 for evidence of an investigation conducted to determine how the window was broken and how the patient was able to elope. There was no evidence provided. Upon interview on 05/17/23, Staff #1 stated, "I believe the patient broke the window with a chair. The window to the unit was replaced by Staff #16." Review of P10's medical record on 05/17/23 revealed a "Medical Staff Daily Progress Note" dated 08/30/22 at 7:41 AM that states, "Problem: pt (patient) eloped from hospital last night, punched window, pushed [unable to read word] way out. Still missing as of this time." Upon interview on 05/17/23, Staff #1 stated, "Yes I remember now. We thought the patient used a chair, but it was thought that [he/she] rolled a gown around [his/her] fist and punched the window." Staff #1 was asked how the facility mitigates the risk of patients breaking the windows, since this incident has shown that the windows can be broken. Staff #1 stated, "We replaced most of the chairs." Staff #1 was unable to address how the facility mitigated the risk of patients breaking a window using their fist.

On 05/17/23 at 12:59 PM, a tour of Room 113 on Unit TU5 unit was conducted. The window identified as the window that was broken by the patient, was repaired. Staff #16, stated that the window that the patient broke was ¼ inch thick and was able to be shattered and that he/she has replaced the window with a 3/8 inch laminated window that won't shatter if broken. Staff #16 stated "I replace windows as they are broken or shattered." Review of the facility's Environmental Risk Assessments for 2021, 2022, and 2023 failed to include a risk assessment for the facility's windows, even after incidents were identified where windows were broken by patients.

Upon interview on 05/19/23 at 10:46 AM, Staff #16 (Director of Plant Ops) stated he/she does environmental rounds once a month. Staff #16 stated, "I used to tour with the ICP but that was a long time ago. I do rounds on my own at least once a month." Staff #16 confirmed that he/she does not tour with an Environmental Tour Team and stated, "It's like herding cats to get people together. [Staff #4] and I were doing it, but now I mostly do it myself." Staff #16 confirmed that he/she does not use an audit tool when rounding. Staff #16 stated, "I carry a pad and jot down anything that needs to be addressed. Then I give a to-do list to my staff." Staff #16 was asked if he/she could provide evidence that the protruding screws found on TU4 were identified during environmental rounds. Staff #16 stated, "Probably not - I'll have to check. I don't always keep track of things in that way." There was no evidence provided indicating the protruding screws were identified during environmental rounds.

Upon interview on 05/19/23 at 11:30 AM, Staff #4 (Director of Risk Management) identified Staff #16 as the Safety Officer. Staff #4 stated, "We do have an audit form - I don't know why [Staff #16] is not using it."

Review of Environment of Care (EOC) meeting minutes provided by Staff #16 for 2021, 2022, and 2023 lacked evidence of monthly environmental rounds conducted in 2022 for the following months: May, June, July, August, September, October, November, and December. Review of the EOC meeting minutes lacked evidence of environmental rounds conducted in 2023 for the following months: May, June, July, August, September, October, November, and December.

3) Reference: Facility policy titled, "Safety Management Plan" (last approved 03/2023) states, " ... The Safety Officer collaborates with the EC (Environment of Care) committee to coordinate risk reduction activities in the physical environment, collect deficiency information, and disseminate summaries of actions and results. The Safety Officer assures that compliance with applicable codes and regulations, as applied to buildings and services. ... Where risks are identified, the current programs and processes to manage those risks are compared to the risks that have been identified. Where the identified risks are not appropriately handled action must be taken to eliminate or minimize the risk. The actions may be creating new programs, processes, procedures, or training programs. Monitoring programs may be developed to assure the risks have been controlled to achieve the lowest potential for adverse impact on the safety and security of patients, staff, and visitors."

During a review of the facility's Environmental Risk Assessment Prevention/Mitigation Plan dated 04/13/21, 04/13/22, and 03/29/23, sprinkler heads located on the ceiling in patient bedrooms and toilets on units TU1, TU3, and TU5, were identified as "Standard but covered by Escutcheon (metal covering)." The mitigation plan states, "CARPAC (internal reporting system) to replace all loopable sprinkler heads submitted internally in May. Awaiting approval. Staff performs Q15 (every 15 minutes) rounds on all patients. Patients at higher risk for suicide attempts are placed on suicide precautions and if necessary, on a higher level of observation."

Upon interview on 05/26/23 at 1:30 PM, Staff #16 confirmed the following:

Escutcheon plates in all patient rooms located on TU1, TU3, and TU5 are easy to remove, providing access to the pipe above and creating a ligature risk. The pipe is capable of supporting a patients weight. These sprinkler heads are accessible to any patient on the unit. Upon interview on 05/26/23, Staff #2 and Staff #34 confirmed that Q15 minute checks are the standard level of observation for patients on all units. Staff performing Q15 minute checks are required to "lay eyes" on the patient every 15 minutes, however, staff do not restrict patient movements and are not focused on the physical environment. Staff #2 and Staff #34 confirmed that no checks are being done above and beyond the standard Q15 minute checks to address the ligature risks that have been identified.

Staff #16 stated that he/she provides bids for contractors and vendors each year and a quote is provided to management each year. Staff #16 stated he/she has been waiting for approval to replace the sprinkler heads since 04/13/21.

4) During a review of facility incident reports conducted 05/16/23 to 05/19/23, the following was identified:

On 11/16/21, Patient #12 (P12) eloped from the facility by jumping the fence in the courtyard. P12 returned to the facility the following day after being taken to the ED by a family member. Review of P12's medical record lacked evidence that the patient was placed on elopement precautions after returning to the facility.

On 02/07/22, Patient #13 (P13) used a lighter to set his/her mattress and blanket on fire in his/her room. Upon interview on 05/17/23 at 1:50 PM, Staff #1 indicated the patient wanted to leave AMA (against medical advice) "but changed [his/her] mind" and returned to the unit. Staff #1 stated, "Unit staff did not recheck the patient and patient's belongings because the patient did not leave the premises. They should have though. The patient's belongings sheet said [he/she] had a lighter upon admission that we couldn't find after the incident. [P13] must have somehow gotten the lighter from his/her bag prior to going back to the unit."

On 08/12/22, Patient #14 (P14) ran out of an exit door on TU4 and down the stairway into the hallway. The incident report indicated P14 pushed a staff member who was "unaware that the patient was following [him/her]."

On 08/29/22, Patient #10 (P10) broke a window on his/her unit and eloped. Review of P10's medical record revealed the P10 was a transfer from another facility. P10's Universal Transfer Form from the sending facility identified him/her as an elopement risk, however, P10 was not placed on elopement precautions upon admission.

On 03/11/23, Patient #15 (P15) was found hiding in a laundry room on his/her unit. Nurse's notes dated 03/11/23 state, " ... [He/She] hided [sic] in the laundry room. Unable to redirect. ... Dr. [name of physician] informed. ... Visible on unit." On 03/12/23, P15 pulled the fire alarm. The Psychiatrist's note dated 03/13/23 states P15 reported pulling the fire alarm because "[he/she] wanted to escape." On 03/17/23, P15 was found hiding in a Social Worker's office on his/her unit. The patient was placed on elopement precautions after the incident on 03/17/23, although he/she was exhibiting elopement behaviors six days prior to the 03/17/23 incident.

On 05/15/23, Patient #8 (P8) eloped from the unit and was found "stuck in the stairwell between TU1 and TU5."

On 05/19/23, a request was made to Staff #4 (Director, Risk Management) for evidence of an investigation into the above referenced incidents, including how the incidents occurred, follow-up or action plans that include remediation of the incidents, and additional staff education or training conducted regarding the incidents. Staff #4 provided an investigation summary for the incident that occurred on 02/07/22. There were no other investigations, remediation of action plans, or evidence of additional staff education or training provided. Upon interview on 05/19/23, Staff #4 stated, "We do follow-up and discuss the incidents, but we don't have documentation of it."

5) Reference: Facility policy titled, "Proper Use and Monitoring of Physical-Chemical Restraints and Seclusion - Acute Final" (last approved 04/2023) states, " ... 14. Staff Training and Competence Assessment: ... Direct care staff and PAs (physician assistants) are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation ... All records documenting completion of training and competency demonstration will be maintained in staff personnel files or credential files. As part of orientation, before performing any of the actions outlined in this policy, and at least annually, training occurs as outlined below. ... 14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs."

During the entrance conference on 05/16/23 at 10:30 AM, Staff #1 and Staff #2 stated direct care staff receive Handle With Care (HWC) training annually and upon hire. Staff #1 stated HWC training teaches staff how to manage violent and aggressive patients and protect the patients and themselves through the use of verbal de-escalation techniques and by safely administering physical holds to the aggressive patient. Staff #1 and Staff #2 stated staff trained in HWC are required to respond to Code 85 emergencies. Staff #1 and Staff #2 stated all direct care staff are required to have annual HWC training. A request was made to Staff #1 and Staff #2 for evidence of staff HWC training for 2021, 2022, and 2023. Review of staff personnel files revealed the following direct care staff did not complete Handle With Care training at the specified time:

i. Staff #14 (LPN) - missing HWC training for 2022
ii. Staff #9 (RN) - missing HWC training for 2022
iii. Staff #7 (Asst. Director of Nursing) - missing HWC training for 2021 and 2022
iv. Staff #24 (Therapeutics Activity Manager) - missing HWC training for 2022
v. Staff #10 (LPN) - missing HWC training for 2021 and 2022
vi. Staff #6 (MHA) - missing HWC training for 2021 and 2023
vii. Staff #25 (Director of Social Work) - missing HWC training for 2023

Upon interview on 05/22/23 at 11:05 AM, Staff #2 stated, "We have recognized that there is a need for more Handle With Care trainings and we are doing that."

Based on review of facility documents and staff interview, it was determined the facility failed to ensure that action plans are developed and implemented when opportunities for improvement are identified.

Findings include:

On 05/25/23 at 11:27 AM, an interview with Staff #17 (S17), Chief Nursing Officer (CNO), was conducted. S17 stated that whenever there is a change in a patient's condition, staff will call a "Code Medic" overhead. Staff from each unit are assigned daily to respond to a "Code Medic." The assigned staff from each unit are responsible to bring a box of medical equipment, the AED (Automated External Defibrillator), an Oxygen tank and an Ambu bag (a device used to provide respiratory support to patients) to the unit where the "Code Medic" was announced. S17 indicated that Staff #7 (S7), Assistant Director of Nursing (ADON), conducts mock codes once a shift every quarter.

Review of the "Code Blue Post Conference Evaluation" form dated 12/03/22, indicated that a Code Blue was called on the TU5 unit, Room 109W for an unresponsive patient. The "Opportunities For Improvement" section of the form stated, "Equipment problems: yes [the yes box was checked] O2 [Oxygen] tank empty ... Staff Competency/Problem? No [the no box was checked] ... ." The "Action Plan" section of the form was left blank. The "Code Blue Evaluation - Debriefing" form states, "... Issues/Problems: 1. Alarm/Building/Equipment function? AED (Automated Defibrillator) initially was not working properly. First O2 machine arrived was empty ... Recommendations: Continue to train every staff in the building." The section "Any Immediate Actions Taken" was left blank.

A request for the staff education/training regarding the empty O2 tank was requested and not received.

Upon interview, S17 stated that each unit is responsible for bringing an O2 tank, so although the first oxygen tank to arrive was not working, there were other oxygen tanks brought to the unit that were working. S17 stated that the staff check the equipment daily and complete a checklist. The "Emergency Medical Equipment Daily Checklist" for December 2022 was requested and reviewed. The checklist indicated that the equipment had been checked on 12/03/22.

The "Code Blue Post Conference Evaluation" forms for 2022 and 2023 were requested. The forms were reviewed and revealed the following:

On 07/29/22 at 1:40 PM, a "Mock Code" was called on the TU2 unit. The "Opportunities For Improvement" section of the form stated, "Equipment problems: yes [the yes box was checked] ... No one brought Emergency Equipment." The "Action Plan" section of the form was left blank. The form was signed by S7.

On 08/24/22 at 3:10 PM a "Mock Code" was called. The location of the event was left blank. The "Code Blue Team" section of the form stated, "unknown." The "Opportunities For Improvement" section of the form stated, "Equipment problems: yes [the yes box was checked] ... No equipment was brought to the code. Staff Competency/Problem? yes [the yes box was checked] ... Staff did not know what to do. Other problems? yes [the yes box was checked] ... there were other staff who responded but turned around when they found out it's a mock code." The "Action Plan" section of the form was left blank. The form was signed by S7.

On 02/28/23 at 3:55 PM, a "Mock Code" was called on the TU3 unit. The "Opportunities For Improvement" section of the form stated, "... Other problems? yes [the yes box was checked] ... Staff who were just coming to the code were not updated on what was going on." The "Action Plan" section of the form was left blank. The form was signed by S7.

On 05/26/23 at 11:54 AM, an interview was conducted with S7. S7 stated that he/she conducts mock codes three times a quarter, during the morning, evening and night shifts. S7 stated that if he/she identified an area of improvement, he/she would report it to the CNO. When asked what actions were taken when opportunities for improvement were identified during the code blue and mock codes, S7 stated, "I don't know why the Action Plan section is not completed."

A request was made to S7 and S17 for any documented evidence of actions taken when the above opportunities for improvement during the code blue and mock codes were identified. No evidence was provided.