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Based on document review, observation, and interview, it was determined that the Hospital failed to provide care in a safe setting and promote each patient's rights, by failing to ensure that patients were safe from ligature risks. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include;

1. The Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the 4 behavioral health units (1A, 1B, 2A, 2B) were free from ligature risks. See deficiency A-144.


The immediate jeopardy was identified on 6/6/2023, due to the Hospital's failure to ensure that care was provided in a safe setting by failing to ensure the patient rooms on the 4 behavioral health units were free from ligature risks. The IJ was cited at 42 CFR 482.13, Patient Rights, and was announced on 6/7/2023 at 1:15 PM, during a meeting with the Chief Executive Officer and Chief Nursing Officer. The IJ was removed by the survey exit date of 6/12/2023.

Based on document review, observation, and interview, it was determined that for 4 of 4 Behavioral Health Units, the Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the behavioral health units were free from ligature risks. This has the potential to affect the current or future patients on suicide precautions admitted to the Hospital.

Findings include:

1. The Hospital's policy titled, "Environment Ligature and Assessment" (dated 1/2023), was reviewed, and required, "[Hospital]'s physical environment is safe and appropriate for a psychiatric hospital. The hospital will complete a Physical Ligature Assessment on an annual basis. The findings from this assessment will be mitigated immediately, either by removing the ligature or limiting that space from being occupied by patients without supervision. The mitigation will be attached to the assessment form..."

2. The Hospital's "Ligature Risk Assessments" for the 4 Behavioral Health units, were completed on 1/2022 and 1/2023. The ligature risk elements/categories, identified toilet seats in the patient bathrooms as ligature risks. The mitigation plan for the toilet seats in the patient bathrooms, included, "staff rounding at minimum of 15 minutes-often times more than that." There was no set plan/date to remove this ligature risk.

3. The Hospital's "Ligature Risk Monitor" rounding tool included, every 15 minute rounding for toilet seats. The tool is used to monitor for any ligature objects placed around the toilet seats.

4. On 6/6/2023 at 10:30 AM, an observational tour of 1A Monarch (Geriatric psych/detox unit), was conducted. The unit had a capacity of 28 with a census of 23. The unit was staffed with 3 Registered Nurse and 3 Mental Health Technicians (MHT). Two of the MHT's were assigned to patient rounds. One of the MHT's was assigned to the "Ligature Risk" monitoring tool. There were no patients on 1:1 observation precaution (direct observation within arm's length). There was 1 patient with a dementia diagnosis that was ordered "Q-10" observation level (every 10 minutes rounding). Thirteen of the 23 patients were on SI (suicidal ideation) precautions. During the tour, a ligature risk was identified. Out of the 14 patient rooms, that had one bathroom each, the toilet had a moveable (u-shaped) seat, that could be used as a ligature point. The hinge of the toilet seat was also raised at least 1 centimeter above the base of the toilet bowl which created a gap that could be used as a ligature point.

- Between 11:30 AM-12:15 PM, tours of the 3 additional behavioral health units (1B General Adult, 2A High Acuity, and 2B Adolescent), were conducted. The ligature risk pertaining to the toilet seats in the patients' bathrooms were identified as well, as each unit had a duplicate layout (each unit has 14 patient rooms).

5. On 6/6/2023 at approximately 11:45 AM, an interview was conducted with the Director of Plant Operations (E #4), stated that the Facility did not have a plan or date set on how they were going to remove the ligature risks involving the toilet seats. E #4 stated that the plan would depend on budget/finance or when they could find a feasible solution. E #4 stated that the only mitigation plan as of right now, is to have the staff do every 15 minutes rounds to monitor for ligature risks.

6. On 6/12/2023 at 10:05 AM, during the unit tours, the Vice President of Facility Management (E #13) stated that they had only purchased one toilet seat initially so that they could test it out before they proceeded to purchase the additional seats for all of the patient rooms. E #13 stated that since they have now confirmed that the new seat will work, they will submit the purchase order to corporate to purchase the additional ligature-resistant seats.

7. On 6/12/2023 at 1:05 PM, the Chief Executive Officer (E #1), presented an email of the purchase order indicating the additional 70 ligature resistant toilet seats had been ordered. The estimated delivery date for 15 of the toilet seats is on 6/13/2023. The remaining 55 toilet seats are expected to arrive on 6/14/2023. E #1 stated that the new toilet seats will be installed within 3 days of their arrival

Based on document review, observation, and interview, it was determined that for 3 of 4 (Pt #1, Pt #5, Pt #7), clinical records reviewed for restraints, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed practitioner.


Findings include:

1. The Hospital's policy titled, "Restraint And/Or Seclusion" (dated 1/2023), was reviewed, and required, "...Registered Nurse...12. Completes required documentation regarding patients in restraint including: Physician's Order must be signed within 24 hours; (Order for Restraint/Seclusion..."

2. The clinical record of Pt. #1 was reviewed on 6/6/2023. Pt. #1 was admitted on 4/5/2023, with diagnosis of major depressive disorder. An order for Restrictive Intervention - Manual Hold was placed to start the manual hold from 4/17/2023 at 2:55 AM to 2:56 AM (1 minute). However, the order was not entered/ordered in the record until 4/18/2023 at 11:25 AM and not signed by the provider/physician until 4/18/2023 at 12:49 PM (greater than 24 hours later).

3. The clinical record of Pt #5 was reviewed on 6/7/2023. Pt #5 was admitted on 4/19/2023, with a diagnosis of bipolar disorder. An order for a manual hold was placed to start on 4/30/2023 at 8:25 PM to 8:35 PM. The order was not entered into the clinical record until 5/2/2023 and was not signed by the provider until 6/4/2023 (greater than 24 hours).

4. The clinical records of Pt #7 was reviewed on 6/7/2023. Pt #7 was admitted on 4/30/2023, with a diagnosis of psychosis. An order for a manual hold was placed to start on 5/3/2023 at 12:53 AM to 1:27 AM. The order was not entered into the clinical record until 6/7/2023 and was not signed by the provider until 6/7/2023 (greater than 24 hours).

5. On 6/7/2023 at 2:35 PM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated that the restraint order should be entered into the computer and signed by the provider within 24 hours.

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Based on document review, observation, and interview, it was determined that the Hospital failed to furnish and supervise nursing services by ensuring that patients at risk for falls had interventions in place/revised to prevent repeated falls and that assessments/medical evaluations were conducted without delay post-fall / injury. This potentially placed all current patients at risk for falls as well as any future patients who may sustain injury at risk for serious harm. As a result, the Condition of Participation. 42 CFR 482.23 Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to ensure that neurological assessments were completed after suspected/actual falls with potential head injury and that medical evaluation/treatment of a patient on blood thinners was not delayed following injury. (A-395 A)

2. The Hospital failed to ensure that patients at risk for falls were monitored for fall precautions; that fall risk interventions were included as part of the patient's treatment plan; and that additional interventions were implemented following a fall incident to prevent repeated falls. (A-395 B)

3. The Hospital failed to ensure that patients at risk for falls had fall prevention measures in place. (A-395 C)

An immediate jeopardy (IJ) began on 4/12/2023, due to the Hospital's failure to ensure that fall precautions were in place; that additional interventions were implemented for a patient with repeated falls; that neurological assessments were completed post-fall(s) with possible head injury; and that a medical evaluation of a patient on blood thinners was not delayed following injury. The IJ was identified on 6/8/2023 and cited at 42 CFR 482.23 Nursing Services, and was announced on 6/8/2023 at 3:00 PM, during a meeting with the Chief Executive Officer and the Chief Nursing Officer. The IJ was not removed by the survey exit date of 6/12/2023.

A. Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #1) reviewed for falls with injury, the Hospital failed to ensure that the nurse supervised and evaluated the nursing care for each patient by failing to ensure that neurological assessments were completed after suspected/actual falls with potential head injury and that medical evaluation of a patient on blood thinners was not delayed following injury.

Findings include:

1. The Facility's policy titled, "Medical Services Encounters" (revised 11/2018), was reviewed and required, "Purpose: To provide for patient's medical needs in a timely manner... The Registered Nurse: ... d. Requests medical services for patient illness, trauma, chronic medical conditions... Medical Services Provider: ... b. Provides treatment for illness, trauma or chronic conditions... d. Writes orders and manages physical problems..."

2. The clinical record of Pt. #1 was reviewed. Pt. #1 was an 82-year old, admitted to the Psychiatric Hospital on 4/5/2023, with diagnoses of major depressive disorder, dementia, anxiety disorder, homicidal ideation, atrial fibrillation, hypertension, and a history of falling. The patient's history & physical and initial nursing assessment indicated that Pt. #1 was alert and oriented (AxO) only to person (x1) with some memory impairment. The assessments noted that there was no pain and no history of musculoskeletal problems such as fractures or joint pain.

- The Master Treatment Plan, initiated 4/6/2023, included Psychiatric Problems of danger to others and elopement and Medical Problems of hypertension, risk for bleeding due to anticoagulant (blood thinner) therapy, and vitamin D deficiency.

- The Medication Administration Record indicated that Pt. #1 received apixaban (Eliquis) [anticoagulation / blood thinner] 2.5 mg (milligrams) orally twice a day for blood clots as ordered from 4/6/2023-4/18/2023 (last dose on 4/18/2023 at 9:55 AM).

- Nursing Progress notes indicated that Pt. #1 had unwitnessed / suspected falls on 4/12/2023, at approximately 1:12 AM and on 4/15/2023, at approximately 1:46 AM. No injuries were noted at the time.

- A Nurse's Note, dated 4/17/2023 at 2:55 AM, included, "At around this time patient was being escorted to his room per Mental Health Technician/MHT [E#5] on floor. Per MHT patient turned unexpectedly and swung at staff member. MHT used CPI [crisis prevention intervention] technique for manual hold on floor from 2:55 AM to 2:56 AM. Patient noted to have abrasion on right lateral side of head/face, ice applied. PRN [as needed] Tylenol... administered at 3:11 AM for complaint of pain 3/10. Patient vitals at the time were the following: Temperature 97.3F, Heart Rate 96, O2 Saturation 96%, Respirations 18, Blood Pressure 173/82. Neurological exam noted to be WNL. Patient alert and oriented x1 to self, which has been baseline for patient." MHT E#5 was noted to land on top of Pt. #1 during the fall. Pt. #1 had no recollection of the fall or how injury was sustained immediately following this incident.

- The Restraint/Seclusion Monitoring record, dated 4/17/2023 at approximately 5:50 AM, included, "Patient is AxO 1-2. Patient has an abrasion on the right side of his forehead and a hematoma [blood pooling under the skin] on the right side of his eyebrow. Patient complained of pain on his upper right side and back, also headache at a level 3. Ice pack was applied and Tylenol was given for the pain..."

- The Daily (Shift) Nursing Assessments and Progress Notes from 4/6/2023-4/18/2023 were reviewed and indicated that Pt. #1 did not report any pain until after the fall incident with MHT E#5 on 4/17/2023. The pain assessment, dated 4/17/2023 at 6:47 AM, indicated a score of 3 out of 10 on the right side of head and right rib cage.

- A nursing assessment on 4/18/2023 at 6:00 AM, included a pain assessment score of 8 out of 10 on the back and legs, and indicated that patient exhibited unsteady ambulation and required use of a wheelchair.

- The record lacked documentation of any increase in nursing assessments or neurological checks implemented after the unwitnessed/suspected falls on 4/12/2023 and 4/15/2023, and the fall with head injury on 4/17/2023.

- Pt. #1 was not evaluated by the a medical provider until the morning of 4/18/2023 (greater than 24 hours later). The Nurse Practitioner/NP's Initial Encounter/Assessment for the Fall, signed 4/19/2023 at 1:49 PM, included, "Patient seen for hospital follow-up on 4/18/2023, fell and hit head prior day. No complaints but with changes in behavior. Unable to ambulate without assistance at time of visit (on arrival [admission to Hospital] ... able to independently ambulate and perform ADLs [activities of daily living]). Decision made to send pt to [Medical Hospital] ER [emergency room] for CT [computerized tomography] head and further evaluation."

- Pt. #1 was transferred via ambulance for medical evaluation/treatment at the emergency room on 4/18/2023, at approximately 10:30 AM (approximately 1 day and 7 hours after the fall with injury occurred).

- Discharge orders and clinical notes, dated 4/18/2023, indicated that Pt. #1 was admitted to the medical hospital for fractures of the sacrum, rib, and right pinky finger. Pt. #1 did not return to the Psychiatric Hospital.

3. An interview was conducted with Nurse Practitioner/NP (E#7) on 6/7/2023. E#7 stated that if the fall incident happened overnight, she will generally see the patient the next morning in person to do her own assessment. E#7 stated that in Pt. #1's case (confused and on blood thinners), "whether or not I was in the building at the time to do an assessment, I would immediately send him out for a CT scan. I can't necessarily detect small bleeds." E#7 stated that the risk of holding the patient there outweighs the risk of sending them out. E#7 stated that there is potential harm in delay if a brain bleed is not detected, it could lead to the patient becoming comatose or even death if gone unrecognized for too long. E#7 stated that the bleed could be small at first and may go undetected especially when the patient is sleeping, you wouldn't notice a change in neurologic status.

4. An interview was conducted with Nurse Practitioner (E#8) on 6/7/2023. E#8 stated that when a patient has a fall, she would put orders to do neuro checks every 45 minutes for the first 2 sets of vitals and then every 4 hours for 24 hours. E#8 stated that if the assessment shows the patient is confused or disoriented, she would send the patient out for a CT. If the patient is baseline confused, "I wouldn't take the risk of waiting." E#8 stated that if a patient has a head fall, they will send out the patient right away. E#8 stated that especially if they are on blood thinners (such as Eliquis), 100% they would call the ambulance and get the patient out right away. E#8 stated that the patient could have internal bleeding, brain bleed, fracture, contusion, dislocation and could continue to decline if treatment is delayed.

5. An interview was conducted with Registered Nurse/RN (E#6) on 6/7/2023, at approximately 9:20 AM. E#6 stated that based on "our (nurses) good judgement, we would get an order to do neuro checks every 4 hours for 24 hours after a fall. E#6 stated that they would assess for any change in the patient's level of consciousness. E#6 stated that in Pt. #1's case since he was baseline confused and he was on blood thinners, E#6 would obtain an order to send the patient out for evaluation at the ER right away, "I wouldn't want to take any chances."

6. An interview was conducted with RN Supervisor (E#9) on 6/7/2023, at approximately 3:42 PM. E#9 stated, "We did notice there was a laceration to right side of the head [post fall]... We brought it up to the medical team... I think they felt comfortable seeing him in the morning. There was a laceration with minimal swelling if any. We started neuro checks which is an automatic every 4 hours. We make sure to get the order for it (neuro checks). The neuro check includes checking the pupils with a flash light and asking some questions, which can be limited due to the severity of Pt. #1's dementia. Can't go much lower than x1, unless the patient is not opening his eyes." E#9 stated that he did not know that Pt. #1 was on blood thinners until after the patient was discharged. E#9 stated, "If we don't necessarily agree with the on-call's decisions, then we take it further and call the person above that, I don't remember who that was. If we couldn't get a hold of the NP, we'd get the medical director involved. We may send the patient over to the hospital to make sure there's no issue."



B. Based on document review, observation, and interview, it was determined that for 1 of 2 patients (Pt. #1) reviewed for multiple fall incidents, the Hospital failed to ensure that the nurse supervised and evaluated the nursing care for each patient by failing to ensure that patients at risk for falls were monitored for fall precautions; that fall risk interventions where included as part of the patient's treatment plan; and that additional interventions were implemented to prevent repeated falls.

Findings include:

1. The Hospital's policy titled, "Fall Prevention Program" (dated 09/22), was reviewed and required, "...Assess patients at risk for falls and place on appropriate precautions... During Hospitalization: Continue to assess the patient for changes in his/her condition and treatment that put them at risk for falls and repeat the fall scale, after each fall and as indicated... The treatment plan will identify any and all individualized interventions to prevent falls... Document all falls, interventions and response to interventions... More intensive interventions may be implemented as the patient requires..."

2. The clinical record of Pt. #1 was reviewed on 6/6/2023. Pt. #1 was an 82-year old, admitted to the Psychiatric Hospital's 1A Geriatric/Detox Unit on 4/5/2023 at 11:25 PM, with diagnoses of major depressive disorder, dementia, anxiety disorder, homicidal ideation, atrial fibrillation, hypertension, and a history of falling.

- Pt #1's Admission Fall Risk Assessment was completed on 4/5/2023. However, the assessment did not include that Pt #1 had a history of previous falls, confused and had impaired memory into the assessment score.

- Precaution Orders, dated 4/06/2023, included: Close Observation/Every 10 Minute Checks; Assault Precautions, and Fall Precautions.

- High Risk Patient Precautions Records (Patient Rounding Flowsheets) from 4/6/2023-4/18/2023 were reviewed and indicated that Pt. #1 was monitored every 10 minutes; however, the records lacked documentation that the patient was monitored specifically for fall precautions from 4/6/2023-4/12/2023 and on 4/17/2023.

- Nursing clinical notes from 4/6/2023-4/18/2023 were reviewed and indicated that Pt. #1 had reported an unwitnessed fall (1st occurrence) on 4/12/2023, at approximately 1:12 AM (no injuries were noted). Pt. #1 was found lying on the floor on 4/15/2023, at approximately 1:46 AM (2nd suspected fall - no injuries were noted). On 4/17/2023, at approximately 2:55 AM, Pt. #1 noted to be wandering the hallway and had sustained injuries during a fall (3rd occurrence) involving a staff member (E#5).

- The Master Treatment Plan, initiated 4/6/2023, included Psychiatric Problems of danger to others and elopement and Medical Problems of hypertension, risk for bleeding due to anticoagulant (blood thinner) therapy, and vitamin D deficiency. The Master Treatment Plan (dated 4/6/2023) and Interdisciplinary Treatment Plan Review/Update on 4/12/2023, did not include any interventions or updates to address the patient's fall risk.

- The record indicated that Pt. #1 remained in room 115 and on every 10 minute rounding during the entire stay from 4/6/2023-4/18/2023. Pt. #1 was not moved to a room closer to the nurses station nor was monitoring increased following any of the suspected / actual fall incidents. The record lacked documentation of fall scale assessments conducted after each fall incident.

3. An observational tour of the 1A Geriatric/Detox unit was conducted on 6/7/2023. The unit consisted of a total of 14 patient rooms, with 7 rooms on each side of the hallway. Room #115 was the second farthest patient room from the nurses station on that side of the hallway.
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4. An interview was conducted with Registered Nurse/RN (E#10) on 6/7/2023, at approximately 8:55 AM. E#10 stated that if a patient has multiple falls even with fall precautions (i.e. socks, mat, leaflets) in place, they would try to make them a 1:1 or line of sight (LOS). E#10 stated that a fall risk assessment is completed only on admission. (E#10 was not aware that fall scale re-assessments should be done after each fall).

5. An interview was conducted with the Nurse Practitioner (E#8) on 6/7/2023. E#8 stated that some fall precautions they put in place for patient's at risk include leaflets on the doors, red bands on the wrists, and non-slip socks. E#8 stated that when a patient has had another incident of falling even when on fall precautions, they would then put that patient on line of sight or 1:1 monitoring.

6. An interview was conducted with RN Supervisor (E#9) on 6/7/2023, at approximately 3:42 PM. E#9 stated that after a fall, "we put the patient on fall precautions if they aren't already on them. After the second or third fall, we usually increase the level of observation to line of sight (LOS) or 1:1 to make sure they don't continue to injure themselves. If it's not getting better with fall precautions in place, we'd get the order for LOS/1:1 and assistance with ADLs [activities of daily living]."

7. An interview was conducted with the Chief Nursing Officer (E #2) on 6/7/2023 at approximately 2:35 PM and again at 3:22 PM. E#2 stated that precaution rounds are completed either every 10 or 15 minutes to ensure that patients are safe and should include the precautions the patients are being monitored for as well as where they are and what their behavior is. E#2 stated that it's important to note the type of precautions on the round sheets because the staff can look at the sheet and need to know what to monitor. For example, a patient on fall precautions should be monitored for steady or difficult gait (walking). E#2 stated that fall prevention includes ensuring that the patients have on non-skid socks, rounding as required, and assessments. E#2 stated that post-fall interventions would include either moving the patient closer to the nursing station; putting them on "line-of-site" precaution; a physical therapy consult; and completing a post-fall huddle form.

8. An interview was conducted with the Mental Health Technician (E#5) on 6/8/2023, at approximately 9:14 AM. E#5 stated that Pt. #1 had Alzheimer's and was constantly getting lost on the unit. The night of the incident, Pt. #1 forgot he had a bathroom in his room and was wandering in the hall until he ended up at the nurse's station. E#5 stated, "I asked him if he needed help and he said he needed to use the bathroom. I was escorting him back to his room and we were about half way down the hall when he became aggressive and started yelling and tried to swing at me. I tried to block him so I grabbed his arm, we lost our footing, and then we both fell on the floor." E#5 was not aware that Pt. #1 had fall incidents prior to this event and was unsure what precautions the patient was on.


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C. Based on document review, observation, and interview, it was determined that for 5 of 7 (Pt #2, Pt #11, Pt #12, Pt #13, Pt #14) patients observed on the behavioral health unit, that were ordered on fall risk precautions, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by not ensuring that fall prevention measures were in place, as required.

Findings include:

1. The Hospital's policy titled, "Fall Prevention" (dated 9/22), was reviewed and required, "...Falls are prevented by creating a safe environment...Assess patients as risk for falls and place on appropriate precautions...High risk fall precautions. 1) Patient will be placed in a room close to the nurse's station. 2) Special signage will be used to alert staff of increased risk for falls (Falling leaf). 3) Patient will wear shoes or YELLOW nonskid socks...Label the patient chart for fall precautions..."

2. On 6/6/2023 at 10:30 AM, an observational tour of the 1A Monarch (Geri-psych/detox) unit was conducted. During the tour, the "Bedboard" (patient census) was reviewed and included patient's precautions. Fourteen patients were on fall precautions. Of the 14 patients on fall precautions, 5 (Pt #2, Pt #11, Pt #12, Pt #13, Pt #14) of these patients that were in the day room, did not have on the required yellow non-skid socks. There were no "fall-leaf" signs (used to indicate patients on fall precautions) on the fall-risk patients' doors or fall risk indicators on their charts, as stated per policy. During the tour, an interview was conducted with a Registered Nurse (E #12). E #12 stated that fall interventions include fall risk bands, fall mats, frequent rounding, and non-skid socks.

3. On 6/6/2023 at 10:55 AM, an interview was conducted with the Chief Nursing Officer (E #2).
E #2 stated that fall prevention includes ensuring that the patients have on non-skid socks, rounding as required, and assessments.