HospitalInspections.org

Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights by ensuring a safe environment. This potentially placed 51 patients on suicide and/or elopement precautions on census as of 8/16/2021, as well as any patients who may become suicidal and/or attempt to elope in the future, at risk for serious harm or death. As a result, the Condition of Participation 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to prevent a patient from jumping out of a 4th floor window, resulting in hospitalization with injuries. See deficiency at A-144 A.

2. The Hospital failed to ensure that the patients' rooms were ligature risk free. See deficiency at A-144 B.

One IJ began on 8/10/2021, due to the Hospital's failure to ensure care in a safe setting for suicidal patients and patients on elopement precautions, by failing to ensure that patients were unable to jump out of the window, and was identified on 8/17/2021, at 42 CFR 482.13, Patient Rights. Another IJ began on 6/17/2021, due to the Hospital's failure to ensure care in a safe setting by failing to ensure suicidal patients' rooms were free from ligature risks, and was identified on 8/17/2021, at 42 CFR 482.13, Patient Rights.

The IJs were announced on 8/17/2021 at 2:15 PM, during a meeting with the Chief Executive Officer (E#1), the Chief Nursing Officer (E#2), the Performance Improvement/Risk Director (E#3), and the Director of Operations (E#5). The IJs were not removed by the survey exit date of 8/18/2021.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 patient (Pt #1) on elopement and suicide precautions, the Hospital failed to ensure care in a safe setting, and Pt #1 jumped from a 4th floor window resulting in hospitalization with injuries. The has the potential to cause serious harm/injury to 35 patients on census as of 8/16/2021 on the 4 North and 3 North Behavioral Health Units.

Findings include:

1. On 8/17/2021, the Hospital's policy titled, "Precautions: Elopement" (November 2014) was reviewed and required, "...Purpose - to provide a secure environment in order to prevent the patient from leaving the hospital without authorization..."

2. On 8/17/2021, the Hospital's policy titled, "High Risk Patient Precautions" (January 2019) was reviewed and required, "...Patients who are identified as high risk will be started on every 10 minute rounds..."

3. On 8/16/2021, Pt #1's clinical record dated 8/9/2021 - 8/10/2021 was reviewed and indicated:
-Intake Assessment, dated 8/9/201 at 2:54 PM, noted, "...Pt #1 presents to Hospital as a direct transfer from another Hospital's emergency department. Pt #1 went to [previous] Hospital's emergency department seeking detox services for heroin use. Pt #1 reported that if he did not receive services and had to leave, he would use heroin again and overdose... Pt #1 presents to Hospital as uncooperative and agitated. Pt #1 verbalized an escape plan and planned to elope from EMS (emergency medical services) during hand-off. Pt #1 cannot contract for safety and requires IP (inpatient) treatment for safety and stability...Diagnosis - Major Depressive Disorder and Opioid dependence..."
-Precautions Orders, dated 8/9/2021 at 3:16 PM, required, "...Precautions - Suicidal Precaution, Assault/Aggression Precaution, Elopement Precaution, Self-Harm and High Risk Precaution...Level of Observation every 10 minutes - Pt #1 is on High Risk Precautions."
-Psychiatric Evaluation, dated 8/10/21, noted, " ...Pt #1 is a voluntary admission admitted for worsening depression with suicidal ideations with plans to overdose ...paranoid and suspicious ...verbalizes feelings of hopelessness, helplessness, guilt, severe anhedonia, apathy, avolition and loneliness. Isolative and withdrawn ...patient demonstrates poor insight, poor judgment, and poor impulse control. Will continue to follow detox protocol as ordered for stabilization ..."
-Suicidal Ideation Severity Assessment, dated 8/10/2021 at 1:14 PM, noted, "Have you started to work out or worked out the details of how to kill yourself? No"
-Pt #1's Safety Rounds, dated 8/9/2021 to 8/10/2021, indicated that Pt #1 was on High risk, Suicide, Elopement, Assault/Aggression and Self-Harm every 10-minute level of observation. Pt #1's safety rounds documented every 10 minutes checks from admission on 8/9/2021 until 8/10/2021 at 6:02 PM.
-Nursing Notes dated 8/10/2021 at 8:36 PM "At approximately 5:50 PM, Pt #1 approached medication room complaining of anxiety and wanting a prn (as needed medication). Pt #1 was given an Ativan 1 mg (antianxiety medication) at 5:53 PM. At 6:10 PM, code brown (someone trying to elope) was called with reports that one of the patients jumped out of the window. Pt #1 was found [outside] on the ground by Hospital staff. Pt #1 was able to communicate with staff, complaining of lower back pain. 911 was called to transfer Pt #1 to [another/medical] Hospital's Emergency Room."

4. On 8/16/2021, Pt #1's incident report, dated 8/10/2021, written by E #5 (Registered Nurse) noted, "Code brown to parking lot was initiated at approximately 6:00 PM. Writer responded along with other staff. We noted unknown patient lying on his left side on pathway adjacent to the building. He is noted to be writhing around in pain, attempting to stand up. Writer along with other staff immediately immobilized patient and requested 911 emergency services be called. Pt #1 advised to remain calm and comply with staff directions. Writer remained until EMS/paramedics arrived. Of note, Pt #1 was conscious and semi-mobile throughout entire time writer was present. Pt #1 taken to [medical] Hospital for further evaluation and stabilization."

5. On 8/16/2021 at 9:30 AM, photos of the broken window were reviewed and it was noted that the rubber stripping had been removed, and the window was on the ground cracked but not shattered.

6. On 8/16/2021 at 2:00 PM, video footage from the 4th floor BHU hallway, dated 8/10/2021 from 5:25 PM to 6:06 PM, was reviewed with E #2 (Performance Improvement/Risk Director). There was no video footage in patient rooms. The video footage noted Pt #1 going into Pt #2's room at 5:57 PM, and Pt #2 leaving the room at 6:03 PM.

7. An observational tour of the 4 North Dual Diagnosis (detox and mental health diagnosis) Adult Behavioral Health Unit was conducted on 8/16/2021, at approximately 10:06 AM. There were 18 patients on census, of which 17 patients were on suicide precautions. There were no patients on elopement precautions. The unit consisted of 10 patient rooms, each with 1-2 windows per room. Each window had an approximately 2 feet by 1-foot window pane on the bottom that was surrounded by a black rubber seal that was accessible from inside the room.

8. An observational tour of the 3 North Women's Adult Behavioral Health Unit was conducted on 8/16/2021, at approximately 10:30 AM. There were 18 patients on census, and all 18 patients were on suicide precautions. There was one patient on elopement precautions as well. The unit consisted of 9 patient rooms, each with 2 windows per room. Each window had an approximately 3 feet by 1 foot window pane on the bottom that was surround by a black rubber seal that was accessible from inside the room (same style as windows on 4 North, only difference is window is wider).

9. On 8/16/2021 at 10:10 AM, an interview was conducted with E#1 (Chief Executive Officer). E #1 stated that the root cause analysis is not complete. E #1 stated that Pt #1 was in the Hospital less than 24 hours. E #1 stated that the Hospital is still trying to figure out what happened, but E #1 stated that he thinks another patient (Pt #2) kicked the shatter proof bottom portion of the window in Pt #2's room & Pt #1 jumped out of the window. E #1 stated that Pt #2 is still in the Facility but he refusing to talk about what happened. E #1 stated that Pt #1 was on elopement precautions (every 10 minute checks). E #1 stated that when Pt #1 jumped out of the window, 911 was called and Pt #1 was sent to the [medical] Hospital. E #1 stated that Pt #1 was admitted to the neurology step down unit with "a burst L2 & L4" (L2 & L4 - lumbar vertebrae). E #1 stated that the Facility did start an RCA (root cause analysis) and that it was not completed as of 8/16/2021. E #1 stated that the maintenance department inspected all the windows in the Facility. E #1 stated that the maintenance department's report, dated 8/13/2021, noted that "No safety or risk issues were noted in all windows inspected ..." E #1 stated that there have not been any elopements in 2021.

10. On 8/17/2021 at 10:15 AM, an interview was conducted with the Medical Director (MD #1). MD #1 stated that he did not see Pt #1. MD #1 stated the E #8 (Nurse Practitioner) saw Pt #1. MD #1 stated that the Hospital notified him when Pt #1 jumped off the ledge. MD #1 stated that from a clinical perspective, Pt #1 was on the right precautions (every 10 minutes) but the issue was with the window. MD #1 stated that the Hospital has to figure out how Pt #1 was able to get out of the window. MD #1 stated that he thinks Pt #1 and Pt #2 worked together timing the every 10 minute checks so that each patient was visible until Pt #1 went out the window. MD #1 stated that there needs to be extra metal on the windows to prevent another patient from accessing the outside and jumping out the window.

11. The root cause analysis initiated by the Hospital on 8/13/2021 did not identify any changes to accessibility/exit through the windows, or changes to patient monitoring and supervision as of 8/17/2021.












39802

Based on document review, observation, and interview, it was determined that for 1 of 1 suicidal patient (Pt. #3) on the 4th Floor Adult Behavioral Health Unit (BHU) and 15 of 15 patients on suicide precautions (SP) on the 1st Floor Geriatric BHU, the Hospital failed to ensure care in a safe setting by ensuring that the patients' rooms were ligature risk free, to prevent potential, serious self-harm to patients. This failure has the potential to affect any current and future patients on the units who may become suicidal and have access to ligature risks.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 8/16/2021, and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. The Hospital's policy titled, "Medical Device Observation" (effective November 2019), was reviewed on 8/17/2021 and included, "Medical devices at [Hospital] are continous oxygen concentrators, CPAP devices, wheelchairs, walkers, canes, crutches and medical beds... Procedure: a. If a patient is identified as requiring a medical device, the nurse will notify the attending physician and place the patient on Q10 (every 10 minute) observation rounds. b. Certain equipment that is not utilized on an a-round-the-clock basis, may be removed from the patient's room and kept at the nurse's station. c. Devices that assist the patient in mobility may be left at the bedside while the patient is in their bedroom..." The policy did not include any additional measures or monitoring required for patients on suicide precautions.

3. During an observational tour of the 4th Floor Dual Diagnosis Adult Behavioral Health Unit on 8/16/2021, at approximately 10:18 AM, a patient (Pt. #3) was alone in the patient's assigned room with a CPAP machine (used to help breathe while asleep) and a walker. The CPAP machine had tubing that was approximately 5-6 feet long and a power cord that was approximately 6 feet long. The walker in the patient's room had open handles and presented as a potential ligature anchor point. The patient was alone in the room, lying in the bed with the door nearly closed and the lights were off (patient was not visible from the hallway without pushing the door open). Pt. #3 was on every 10 minute SP (suicide precautions); however, was not on one-to-one supervision.

4. The clinical record of Pt. #3 was reviewed on 8/16/2021. Pt. #3 was admitted on 8/12/2021, with diagnoses of major depressive disorder, with suicidal ideation (SI), and alcohol withdrawal/detox. Pt. #3 was placed on precautions for High Risk Suicide, Falls, and use of a Medical Device, on 8/12/2021 at 3:16 PM, which included orders for Q10 (every 10) minute safety observations. There were no orders for one-to-one safety monitoring.

- The Psychiatric Evaluation, dated 8/13/2021 at 2:49 PM, included: "[Pt. #3] with Depression and Alcohol Dependence, who presented with suicidal ideation with a plan to shoot himself with a gun, is high risk for harm... can have episodes of helplessness and hopelessness and worthlessness... The patient is high risk for harm and a safety concern, unpredictable, and highly agitated... Patient is at increased ligature risk due to medical equipment and Patient resides in a room with medical equipment..."

- Nurse's Note on 8/15/2021 at 9:45 AM included, "...sulks in his [Pt. #3's] medical problems that makes his life not worth living."

- Nurse's Note on 8/15/2021 at 11:26 AM included, "[Pt. #3] has suicidal thoughts that comes and goes, unable to contract for safety."

- Nurse's Note on 8/16/2021 at 12:33 AM included, "Patient has SI thoughts due to unable to contract for safety."

- Physician's Progress Note on 8/16/2021 at 9:27 AM included, "Patient has SI and no plan, is unable to contract for safety, has depression... episodes of impulsivity... feelings of guilt and hopelessness, poor sleep..."

5. An observational tour of the 1st Floor Geriatric BHU was conducted on 8/16/2021, at approximately 3:35 PM. There were 19 patients on census, of which 15 patients were on SP. Five of the 10 rooms had medical beds with 4 siderails, a headboard and foot board with openings that could be used as anchor points for hanging, and 2 foot power cords that were ligature risks. Eight of the 9 patients assigned to these five rooms with medical beds were on SP. One room also had a movable, over-bed tray table that could be used as an anchor point. Both patients assigned to the room with the tray table were on SP. During the tour, these rooms with medical beds and a tray table were open, unlocked and accessible to other SP patients on the unit. Patients in rooms with medical beds were on every 10 minutes rounds. No one was on one-to-one monitoring. At approximately 3:38 PM, an oxygen concentrator with an approximately 6 foot long power cord with 6 foot long oxygen tubing attached was observed left unattended in a patient's (Pt. #5) room, accessible by any patient on the unit. Pt. #5 also had a medical bed in the room. The patient was not in the room at that time, and the door was left open. Pt. #5 was on every 10 minute SP precautions; however, was not on one-to-one supervision.

6. An interview was conducted with the Mental Health Technician (E#7) on the 4th Floor BHU on 8/16/2021, at approximately 10:20 AM. E#7 stated that Pt. #3 only uses the medical device when he is sleeping and is supposed to return it to the nurse when Pt. #3 is done with it. E#7 stated that Pt. #3 is on high risk suicide precautions and is monitored every 10 minutes. E#7 stated that Pt. #3 is not on one-to-one monitoring and may use the CPAP in his room alone but the door needs to be open a crack.

7. The Ligature Risk Assessment, done by the Hospital on 6/17/2021, identified beds as a high ligature risk and indicated that a "mitigation plan will be put in place immediately." The Assessment did not identify tray tables as potential ligature risks.

8. The Ligature Risk Mitigation Plan was provided by the Director of Operations (E#5) on 8/17/2021, at 9:38 AM. E#5 stated that the mitigation plan was last updated in 2020 and was not updated in 2021, as there were no changes. The Mitigation Plan included, "Medical Beds: Immediate mitigation & Proposed Correction: Place rounds at various times not to exceed 15 minutes. Door will be left open while occupied and closed and locked when unoccupied... Misc Medical Equipment: Place on rounds at various times not to exceed 15 minutes. Door will be left open while occupied and closed and locked when unoccupied."

9. An interview was conducted with the Chief Nursing Officer (E#2) on 8/17/2021, at approximately 9:50 AM. E#2 stated that every patient using a medical bed or medical equipment is placed on every 10 minute rounds. E#2 stated that patients may use the medical equipment while alone in their rooms.

10. An interview was conducted with the Medical Director (MD#1) on 8/17/2021, at approximately 10:18 AM. MD#1 stated if possible, patients will be monitored by staff more visibly in the day room area when using medical equipment such as oxygen. MD#1 stated that if a patient is going to use a CPAP for example while asleep in the patient's room, the patient should be continuously monitored while using their medical equipment by a staff member.