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Based on observation, document review and interview, it was determined that the Hospital failed to ensure that the patient rights were protected. This placed current and future patients for self-harm/injury. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure safety interventions were provided and maintained, due to the presence of ligature risks on the 4 East Behavioral Health Unit. See deficiency A-144.

Based on observation, document review and interview, it was determined that the Hospital failed to ensure safety interventions were provided and maintained, due to the presence of ligature risks on the 4 East Behavioral Health Unit. This has the potential to affect the safety of the 30 psychiatric patients on census as of 06/09/2021, and any future psychiatric patients who become suicidal.

Findings include:

1. An observational tour was conducted on the 4th Floor-Behavioral Health Unit (4 East) on 06/09/2021, between 11:00 AM to 11:15 AM. The following was observed:

- One patient room (452) with medical beds identified as a ligature risk (the side rails could be used as anchor points).
- Pt. #11 was assigned to one of the beds in room 452. Pt. #11 was on suicide precautions and did not have a 1:1 (Direct observation) sitter.

2. The clinical record of Pt. #11 was reviewed on 6/9/2021. Pt. #11 was admitted on 06/08/2021 2:05 PM with a diagnosis of major depressive episode. The clinical record included, "...Presents with c/o (complaint of) SI (suicidal ideation's), has been having suicidal ideations for few months with multiple attempts. Currently wants to drink poison to end her life." The Observation Precaution sheets for 06/08/2021 through 06/09/2021 indicate type of precaution: SP/CO (Suicide precautions/Continuous Observations).

3. The Hospital's Pro-Active Risk Assessment, dated 01/2021, was reviewed on 06/09/2021, and indicated that the ligature risks for the two (2) medical beds on unit was identified and included, "...Medical beds ...do not have solid side rails. Under structure bars present an opportunity for looping and hanging...Any suicidal patient would also have 1:1 (direct supervision) monitoring."

4. The Facility's policy titled "Suicide Assessment and Prevention" was reviewed on 06/09/2021 at approximately 2:00 PM, and included, " ...Patients who are assessed to be at moderate or high risk for suicide may be placed on line of sight observation on a one to one (1:1) observation ...8.) Remove all potential ligatures ..."

5. On 06/09/2021 at approximately 11:10 AM, the finding were discussed with Chief Nursing Officer (E #1). E #1 stated that patients with suicidal ideation's should not be placed in a bed in the room with medical beds.

6. On 06/09/2021 at approximately 2:30 PM, an interview was conducted with Mental Health Technician (E #14). E #14 stated that she was assigned as the 1:1 sitter for Pt. #11 at 2:00 PM.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for use of restraints, the Hospital failed to ensure that a less restrictive intervention was used prior to the use of restraints.

Findings include:

1. The Hospital's policy titled, "Restraints, Use of and Alternative Measures for Violent and/or Self Destructive (V/SD) Patients" (revised 1/31/19) was reviewed and included, "... 2. Mechanical restrains are prohibited except for patients who exhibit intractable behavior that is severely self-injurious or injurious to others and who has not responded to traditional interventions or who are unable to contract with staff for safety... 5. Less restrictive interventions should be attempted prior to the use of restraints or seclusion.."

2. On 06/09/2021 at approximately 10:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2's clinical record included the following:

- Pt. #2 was admitted on 06/01/2021 with diagnosis of Bipolar Disorder.
- Nurses note dated 06/06/2021 at 01:20 PM included, "(Pt. #2) drinking deodorant and picking at her skin until she bled, not following the redirection of staff, patient in 4-point restraints."
-Restraint order form dated 06/06/2021 at 1:20 PM through 4:00 PM, indicated that patient was placed in 4 extremities restraints. The clinical record lacked documentation that less restrictive interventions were offered prior to the use of restraints.

3. On 06/09/2021 at approximately 11:49 AM, an interview was conducted with the Manager of Psychiatry (E #10). E #10 stated that restraints should be the last resort when trying to redirect behaviors. We would utilize other interventions such as safety contracts.

4. On 06/09/2021 at approximately 12:45 PM, an interview was conducted with Attending Psychiatrist (MD #1). MD #1 stated, "When a patient is displaying self-harm that are not drastic behaviors, we offer alternative interventions, redirection and medication before we restrain the patient..."

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for restraints, the Hospital failed to ensure the discontinuation of restraint use at the earliest possible time, as required.

Findings include:

1. The Hospital's policy titled "Restraints, Use of and Alternative Measures for Violent and/or Self Destructive (V/SD) Patients" (revised 1/31/19) was reviewed and required, "...8. The Hospital discontinues restraints or seclusion at the earliest possible time, regardless of the scheduled expiration of the order. 5. Assessment for potential discontinuance or continued use of restraints is ongoing and occurs with each reassessment..."

2. On 06/09/2021 at approximately 10:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2's clinical record included the following:

- Psychiatric Evaluation dated 06/01/2021, at 3:33 PM included, " ...History of present illness:...HI/SI (homicidal ideation/suicidal ideation) ..."
- Restraint Order Form dated 6/3/2021 at 12:15 - 4:15 PM, included, "Initiated on 6/3/2021 at 12:15 PM, Violent and/or Self-Destructive 1) Type of Restraint: 4-Extremities..."
- Restraint/Alternative Flowsheet dated 6/3/2021 from 12:15 PM to 4:15 PM, included, "... B. Behavior/Response: at 12:30 PM through 4:15 PM, (Pt. #2) 1. Calm... E. Type of Restraint: 4-Point..."

3. On 06/09/2021 at approximately 11:11 AM, an interview was conducted with Clinical Coordinator of Behavioral Health Unit (E #9). E #9 stated, "The criteria for release from restraints is when a patient has been calm and cooperative for 15 minutes x (times) 2". E #9 stated that Pt. #2 should have been released from restraints her behavior is documented as calm for at least 30 minutes.

4. On 06/09/2021, at 1:45 PM an interview was conducted with Registered Nurse (E # 12). E #12 stated, "I did not release Pt. #2 from the restraints until the end of the 4-hour order because it seemed like she (Pt. #2) had an aura (feeling) around her and she was not ready."

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required.

Findings include:

1. The Hospital's policy titled "Restraints, Use of and Alternative Measures for Violent and/or Self Destructive (V/SD) Patients" (revised 1/31/19) was reviewed and required, "...11. a. An LIP (Licensed Independent Practitioner) or HOA (Hospital Operations Administrator) or RN (Registered Nurse) must do a face-to-face evaluation within one (1) hour after the restraint is applied..."

2. On 06/09/2021 at approximately 10:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2's clinical record included the following:
-Pt. #2 admitted on 06/01/2021 with diagnosis of Bipolar Disorder.
-Psychiatric Evaluation dated 06/01/2021, at 3:33 PM included, " ...History of present illness:...HI/SI (homicidal ideation/suicidal ideation) ...
-Restraint Order Form dated 6/6/2021 at 1:20 PM-4:00 PM, included, "Initiated on 6/6/2021 at 1:20 PM, Violent and/or Self-Destructive 1) Type of Restraint: Medium, 4-Extremities..." The form lacked documentation that a Face-to-Face Assessment was completed within one (1) hour of restraint initiation.

3. On 6/10/2021 at approximately 1:30 PM, an interview was conducted with the Chief Nursing Officer (E #1). E #1 stated that a 1-hour Face-to-Face Assessment must be completed and documented within one hour of initiating restraints.