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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The Governing Body (guides the hospital's long term goals and policies, strategic planning, and decision-making to ensure delivery of quality patient care) failed to ensure the nursing services department implemented and abode by the standards of practice with regards to unit rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) to assure safe delivery of care, after an incident of attempted hanging by Patient 1 on 7/28/2023. This failure had the potential to result in patients keeping contraband (prohibited items), staff not identifying ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in the room, and had the potential for self-harm for patients in the BHU. (Refer to A - 0063)

2. The Governing Body failed to ensure the Department of Plant Operations installed metal plates around the shelving units (dressers) to close the gaps between the shelving units and the wall, in an effort to remove ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risk in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), after Patient 1 attempted to hang himself by attaching a bedsheet between the gap in the wall and the shelving unit and wrapping the sheet around his neck on 7/28/2023. This deficient practice had the potential to compromise patient safety in the BHU, due to the presence of ligature risk in patient rooms. (Refer to A - 0083)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on observation, interview, and record review, the Governing Body (guides the hospital's long term goals and policies, strategic planning, and decision-making to ensure delivery of quality patient care) failed to ensure the nursing services department implemented and abode by the nursing standards of practice with regards to unit rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) to assure safe delivery of care, after an incident of attempted hanging by Patient 1 on 7/28/2023.

This failure had the potential to result in patients keeping contraband (prohibited items), staff not identifying ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in the room, and had the potential for self-harm for patients in the BHU.

Findings:

During an observation on 09/18/2023 at 1:20 p.m. in the Behavioral Health Unit (BHU), the Clinical Nurse Partner (CNP) 1 conducted rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) and peeked through the windows in three of three patient rooms. Room doors were closed. CNP 1 did not enter the rooms.

During an interview on 09/18/2023 at 1:28 p.m. with CNP 1, CNP 1 stated, "I have to get in the rooms every 15 minutes." CNP 1 also stated "after lunch I did not go into the room. I just look through the window."

During an interview on 09/18/2023 at 1:38 p.m. with unit manager (UM)1. UM 1 stated CNPs made rounds to check the environment and to look at what patients were doing. The CNPs would make sure there was no contraband in the room. UM 1 stated "they are required to go into the room. Open the door and check." The CNP also confirmed that patient rounding is an expectation from staff and is a standard practice in the BHU.

During an interview on 09/18/2023 at 3:12 p.m. with the Vice President of Behavioral Health Unit (VPBHU), VPBHU stated when conducting the rounding, staff should walk into the room all the way to the shower room because something could be broken in the restroom and there could be environmental hazards. VPBHU also stated it was important to go into the room and check because someone (a patient) could have passed out and/or doing something inappropriate or unsafe in the room.

During an interview on 9/22/2023 at 10:13 a.m., with the Chief Medical Officer (CMO), the CMO stated the following. The Governing Board or Governing Body (guides the hospital's long-term goals and policies, strategic planning, and decision-making to ensure delivery of quality patient care) oversees and is responsible for all the activities in the hospital. The CMO was aware of the incident that occurred on 7/28/2023 when Patient 1 attempted to hang himself by attaching a bedsheet between the wall and the shelving unit in the Behavioral Health Unit (BHU). The CMO stated the incident had not yet been reported to the Governing Body. After the incident, the BHU implemented enhanced patient rounding which included checking for and removing excess bedsheets.

During an interview on 9/22/2023 at 2:21 p.m., with the CMO, the CMO stated the following, regarding oversight by the Governing Body (GB, or Governing Board). If there are safety concerns, the GB rely on the nurse managers from the units to address the issues. The CMO stated "We take their word for it, it's an honor system."

During a review of Patient 1's "Inpatient Face sheet," the Face Sheet indicated Patient 1 was admitted to the facility on 7/28/2023 for depressive disorder (or depression, depressed mood or loss of pleasure or interest in activities for a long period of time).

During a review of Patient 1's "Behavior Health Unit 15 - Minute Rounding Log," dated 7/28/2023, the log indicated the following. At 2:30 p.m., Patient 1 was observed in Patient 1 ' s room and lying in bed.

During a review of Patient 1's nurses note, dated 7/28/2023 at 2:54 p.m., the note indicated at 2:30 p.m., "Patient 1 was found in his room with a wet blanket around his neck. The blanket was "dugged-in (burying)" behind the drawer. CPR (Cardiopulmonary resuscitation, a life-saving procedure performed when the heart stops beating) started. Code blue (indicated a patient requiring resuscitation [reviving} or in need of immediate medical attention) was called. Response team (made up of physician, nurse, respiratory therapist, etc.) came. Patient 1 was transferred to ED (Emergency Department-responsible for the administration and provision of immediate medical care to the patient upon the patient ' s arrival to the facility)."

During a review of Patient 1's "Code Blue Record," dated 7/28/2023, the record indicated Patient 1 was in his room. Patient 1 was unconscious, no breaths and no pulse. Chest compressions (the act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation) started at 2:32 p.m. Bag-valve-mask ventilation (use of a hand-held tool to deliver positive pressure ventilation [process of air flowing into the lungs and out of the lungs] to a patient with insufficient or ineffective breaths) started at 2:33 p.m. Patient 1 was resuscitated (revive from unconsciousness or apparent death) and transferred to the ED at 2:40 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Patient Observation #100.15 (unit rounding)," dated 1/20/2023, the P&P indicated patient rounding is done using acute observation. Acute observation (rounding) is performed on the unit as a tool to ensure patient and environmental safety ...Rounding at regular intervals is designed to ensure that each patient is observed by a staff member who can quickly assess the patient's overall condition and then raise alerts if the patient ' s status has changed significantly of if a safety concern is noted in the environment. Staff will visualize and listen for signs of distress, and if possible, briefly converse with each patient on each round to assess for indicators of safety/medical needs, behavior/mood/thought changes, and current activity ...Environmental and safety checks are also conducted on each round.



During a review of facility's "Amended and Restated Bylaws," last amended on 11/30/2022, the Bylaws indicated the following. Article VIII, Quality of Professional Services. Section 1. Board of Directors Responsibility. The Board of Directors shall require ...(b) that there is one level of patient care in the Medical Center, so that all patients with the same health problems receive the same level of care, consistent with the professional standards of the community and the Medical Center ...(c) that the person or body (e.g., Medical Staff department or committee) responsible for oversight of each basic and supplemental service provided in the Medical Center, shall cause written policies and procedures to be developed and maintained for such service, and that such policies and procedures are approved by the Board.

Based on observation, interview, and record review, the Governing Body (guides the hospital's long term goals and policies, strategic planning, and decision-making to ensure delivery of quality patient care) failed to ensure the Department of Plant Operations (administers and direct programs to maintain the facility's buildings, grounds, environment, and equipment to ensure safe and efficient operations) completed the installation of metal plates around the shelving units (dressers) to close the gaps between the shelving units and the wall, in an effort to remove ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risk in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), after Patient 1 attempted to hang himself by attaching a bedsheet between the gap in the wall and the shelving unit and wrapping the sheet around his neck on 7/28/2023.

This deficient practice had the potential to compromise patient safety in the BHU.

Findings:

During an observation on 9/18/2023 beginning at 12:07 p.m., in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), the following was observed. Fourteen (14) of 15 patient rooms had a ½ to 1-inch gap between the anchored wood shelving units (or dressers) and the wall. The gap could be used as an anchor point for ligature. One (1) of 15 shelving units had a "L"- shaped bracket or channel (purpose is to close a gap) attached to the top of the shelving unit, that closed the gap between the shelving unit and the wall. Twenty-three (23) patients occupied the affected rooms.

Concurrently, during an interview on 9/18/2023 at 12:46 p.m., with the Supervisor of Plant Operations (SPO), the SPO stated the following. The "L" shaped bracket was put in place to anchor the shelving unit to close the gap between the shelving unit and the wall to prevent patients from hanging themselves. The SPO could not recall the exact date but stated an incident occurred over a month ago, where a patient (Patient 1) attempted to hang himself by attaching a bedsheet to the shelving unit and wrapped it around his neck. The SPO received a work order to place "L" channels on all shelving units in the BHU over a month ago. The SPO stated he just installed the first "L" bracket (channel) today (9/18/2023) because the SPO needed the materials to start the project. The SPO stated he had the materials onsite and just found the materials today (9/18/2023).

During an interview, on 9/18/2023 at 3 p.m., with the Vice President of the Behavioral Health Unit (VPBHU) and the Regulatory Compliance & Patient Safety Manager (RCPSM), the VPBHC and RCPSM stated the following. On 7/28/2023, a patient (Patient 1) attempted to hang himself by wrapping a bedsheet around his neck and attaching the bedsheet between the gap of shelving unit (or dresser) and the wall. Patient 1 was given CPR (Cardiopulmonary resuscitation, a life-saving procedure performed when the heart stops beating) and transferred to the Emergency Department (ED, responsible for the administration and provision of immediate medical care to the patient upon the patient ' s arrival to the facility). Patient 1 was intubated (a tube is inserted through a person's mouth or nose and into the airway to keep, to keep the airway open) and transferred to the Intensive Care Unit (ICU- which provides continuous treatment for patients who are seriously ill). The VPBHU stated that after the incident, there was a delay in closing the gaps between the shelving units and the wall because the VPBHU was unsure as to whether to remove the shelving unit or place brackets on the dressers to remove the gap. The first "L" - shaped bracket (channel) was installed today (9/18/2023). The VPBHU and the RCPSM acknowledged the delay in closing the gaps had posed a ligature risk for patients in the BHU.

During a concurrent interview and record review, on 9/18/2023 at 4:03 p.m., with Unit Manager (UM) 1 and Quality Review Nurse (QRN) 5, the UM 1 and QRN 5 stated that all patients in the BHU were at risk of self-harm.

During an interview on 9/21/2023 at 1:45 p.m., with SPO and the Assistant Director of Plant Operations (ADPO), the SPO and ADPO stated Patient 1 attempted to hang himself on 7/28/2023. SPO and ADPO received a work order on 8/14/2023 to place metal plates around the dressers in the BHU and must be completed ASAP (as soon as possible). The SPO and ADPO stated the request's priority was "Priority 1." meaning it was top priority and should be completed within 1 - 2 days. The SPO stated the first metal plate was placed on 9/18/2023.

During an interview on 9/22/2023 at 10:13 a.m., with the Chief Medical Officer (CMO), the CMO stated the following. The Governing Board (Body) oversees and is responsible for all the activities in the hospital. The CMO was aware of the incident that occurred on 7/28/2023 when Patient 1 attempted to hang himself by attaching a bedsheet between the wall and the shelving unit in the Behavioral Health Unit (BHU). The CMO stated the incident had not yet been reported to the Governing Body. After the incident, the BHU implemented enhanced patient rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) which included checking for and removing excess bedsheets.

During an interview on 9/22/2023 at 2:21 p.m., with the CMO, the CMO stated the following, regarding oversight by the Governing Body (GB, or Governing Board). If there are safety concerns, the GB rely on the nurse managers from the units to address the issues. The CMO stated "We take their word for it, it's an honor system."

During a review of Patient 1's "Inpatient Face sheet," the Face Sheet indicated Patient 1 was admitted to the facility on 7/28/2023 for depressive disorder (or depression, depressed mood or loss of pleasure or interest in activities for a long period of time).

During a review of Patient 1's Emergency Department (ED) note titled "HPI (history of present illness) ED General," dated 7/28/2023 at 12:46 a.m., the ED note indicated "Patient 1 had a past medical history of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression, brought in by the police department for a 5150 (72-hour) hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for suicidal (intentionally taking your own life) gesture tonight ...Patient 1 has self-inflected neck abrasion and bilateral wrist lacerations (cuts)."

During a review of Patient 1's nurses note, dated 7/28/2023 at 2:54 p.m., the note indicated that at 2:30 p.m., Patient 1 was found in his room with a wet blanket around his neck. The blanket was "dugged-in (burying)" behind the drawer. CPR (Cardiopulmonary resuscitation, a life-saving procedure performed when the heart stops beating) started. Code blue (indicated a patient requiring resuscitation [reviving} or in need of immediate medical attention) was called. Response team came. Patient 1 was transferred to ED.

During a review of Patient 1's ED note titled "HPI (History of Present Illness) - ED General," dated 7/28/2023 at 2:57 p.m., indicated the following: "Chief complaint: Cardiac arrest (heart stopped)/CPR. Patient 1 was in the BHU. There was a code blue called ...Patient 1 was on the floor in his room, CPR was in progress. Staff there said Patient 1 was found with a sheet around his neck. The staff started CPR immediately after Patient 1 was found and noted to have no pulse ...Patient 1 regained a pulse, was given supplemental oxygen and immediately brought to the ED. Procedures: Rapid Sequence Intubation (a technique that is used when a rapid control of the airway is needed as a precaution for a patients that may have risk of pulmonary aspiration [a condition in which food, liquid, saliva, or vomit is breathed into the airway])."

During the review of a document titled, "Request Work Order," dated 8/14/2023, the work order indicated the following: "Location: BHU. Priority: 1 - Emergency/Safety. Requested Remarks: Metal plates around dressers must be completed asap (as soon as possible). Incident occurred on unit." The completion by (signature of the person who completed the Request Work Order) and date (Date when Request Work Order was completed) was blank.

During a review of the facility's policy and procedure (P&P) titled, "Contraband (prohibited items) Items #200.07," dated 5/2023, the P&P indicated the BHU will provide and maintain a safe environment at all times.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. Fourteen (14) of 15 patient rooms in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) had ½ to 1-inch gaps between the anchored wood shelving units (dresser) and the wall, where the shelving units could be used as an anchor point for ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). This deficient practice resulted in the attempted hanging of one of seven sampled patients (Patient 1) in the BHU and had the potential for self-harm for all twenty-three (23) of 24 patients, including five (5) of 7 sampled patients (Patients 2, 3, 4, 5, and 6) in the BHU. (Refer to A-0144)

2. Four of 15 patient rooms in the BHU had ½ to 1-inch gaps between the electrical conduits (a tube used to protect and route electrical wires within a structure) and the wall located above the wall light, which could be used as an anchor point for ligature. This deficient practice had the potential for self-harm for six (6) of seven sampled patients (Patients 2, 3, 4, 5, 6, and 7) in the BHU. (Refer to A-0144)

3. One of two Clinical Nurse Partners (CNP 1) failed to conduct proper rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) in three (3) of 3 patient rooms in the BHU by peeking through the windows instead of entering the patients' rooms to check patient safety and environmental hazards. This failure had the potential to result in patients keeping contraband (prohibited items) and staff not identifying ligature risk in the room. (Refer to A-0144)

4. Ambu Bags (a device to provide respiratory support) were not readily stocked on two of two emergency carts (crash cart, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment) in the critical care unit (provides medical care for patients with life-threatening conditions or illnesses). This failure had the potential to result in endangering patient's life by delaying the ability to provide respiratory support in an emergency. (Refer to A-0144)

The cumulative effective of these deficient practices resulted in the facility's inability to provide a safe patient care environment.

Based on observation, interview and record review, the facility failed to ensure patients received care in a safe environment, as evidenced by:

1. Fourteen of 15 patient rooms in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) had ½ to 1-inch gaps between the anchored wood shelving units (dressers) and the wall, where the shelving units could be used as an anchor point for ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). This deficient practice resulted in the attempted hanging of one of seven sampled patients (Patient 1) in the BHU and had the potential for self-harm for all twenty-three (23) of 24 patients including five (5) of 7 sampled patients (Patients 2, 3, 4, 5, and 6) in the BHU.

2. Four of 15 patient rooms in the BHU had ½ to 1-inch gaps between the electrical conduits (a tube used to protect and route electrical wires within a structure and the wall located above the wall light, which could be used as an anchor point for ligature. This deficient practice had the potential for self-harm for six (6) of seven sampled patients (Patients 2, 3, 4, 5, 6, and 7) in the BHU.

3. One of two Clinical Nurse Partners (CNP 1) failed to conduct proper rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) in three (3) of 3 patient rooms in the BHU by peeking through the windows instead of entering the patients' rooms for to check patient safety and environmental hazards. This failure had the potential to result in patients keeping contraband (prohibited items) and staff not identifying ligature risk in the rooms.

4. Ambu Bags (a device to provide respiratory support) were not readily stocked on two of two emergency carts (crash cart, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment) in critical care unit. This failure had the potential to result in endangering patient's life by delaying the ability to provide respiratory support in an emergency.

On 9/18/2023 at 5:48 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Quality Review Nurse (CRN) 1, Regulatory Compliance & Patient Safety Manager (RCPSM), Assistant Director of Plant Operations (ADPO), Vice President of the Behavior Health Unit (VPBHU), Assistant Director of Nursing (ADON), Director of Emergency Services (DES), Corporate Director of Nursing (CDON), and the Chief Medical Director (CMO). The facility failed to maintain a safe environment, free of ligature risk (or ligature point, anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation), after Patient 1 attempted to hang himself on 7/28/2023, by attaching a bedsheet between the gap of the wall and a shelving unit in the Behavioral Health Unit (BHU). The gap between the wall and the shelving unit was observed in 14 of 15 patient rooms. In addition, gaps between the wall and electrical conduits (a tube used to protect and route electrical wires within a structure) located above the wall light and were reachable by standing on the nightstand creating a ligature risk in 4 of 15 patient rooms. Moreover, staff looked through windows instead of entering patient rooms to perform patient safety and environment safety checks. These deficient practices resulted in Patient 1 hanging himself, requiring cardiopulmonary resuscitation (CPR, a life-saving technique that is useful in emergencies when someone ' s breathing or heartbeat has stopped) and transfer to the emergency department (ED, responsible for the administration and provision of immediate medical care to the patient upon the patient's arrival to the facility) and had the potential for self-harm by all 24 patients in the BHU.

On 9/22/2023 at 4:28 p.m., the IJ was removed in the presence of the Director of Performance Improvement (DPI), Corporate Director of Plant Operations (CDPO), Vice President of Nursing (VPN), Chief Nursing Executive (CNE) 2, CMO, Corporate Director of Risk Management (CDRM), CNE 1, and the CDON after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan included closing the gaps between the walls of the shelving units and the electrical conduits, staff re-education and random audits regarding proper rounding for environmental hazards and patient safety.

Findings:

1. During an observation on 9/18/2023 beginning at 12:07 p.m., in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), the following was observed. Fourteen (14) of 15 patient rooms had a ½ to 1-inch gap between the anchored wood shelving units (or dressers) and the wall. The gap could be used as an anchor point for ligature. One (1) of 15 shelving units had a "L"- shaped bracket or channel attached to the top of the shelving unit, that closed the gap between the shelving unit and the wall.

Concurrently, during an interview on 9/18/2023 at 12:46 p.m. with the Supervisor of Plant Operations (SPO), the SPO stated the following. The "L" shaped bracket was put in place to anchor the shelving unit to close the gap between the shelving unit and the wall to prevent patients from hanging themselves. The SPO could not recall the exact date but stated an incident occurred over a month ago, where a patient (Patient 1) attempted to hang himself by attaching a bedsheet to the shelving unit and wrapped it around his neck. The SPO received a work order to place "L" channels on all shelving units in the BHU over a month ago. The SPO stated he just installed the first "L" bracket today (9/18/2023) because the SPO need the materials to start the project. The SPO had the materials onsite and just found the materials today (9/18/2023).

During an interview, on 9/18/2023 at 1:30 p.m. with Registered Nurse (RN) 1 and Unit Manager (UM) 1, RN 1 and UM 1 stated the following. Four to six weeks ago, an incident occurred where a patient (Patient 1) attempted to hang himself by attaching a bedsheet between the gap of the shelving unit and the wall and wrapping the bedsheet around his neck. Patient 1 was found unconscious by his roommate, who reported it nursing staff. Nursing staff found Patient 1 in a sitting position in front of the shelving unit with the bedsheet wrapped around his neck. Patient 1 was given CPR (Cardiopulmonary resuscitation, a life-saving technique that is useful in emergencies when someone's breathing or heartbeat has stopped), a code blue (indicated a patient requiring resuscitation [reviving} or in need of immediate medical attention) was called, and Patient 1 was transferred to the Emergency Department (ED, responsible for the administration and provision of immediate medical care to the patient upon the patient's arrival to the facility) for further evaluation.

During an interview, on 9/18/2023 at 3 p.m., during an interview with the Vice President of the Behavior Health Unit (VPBHU) and the Regulatory Compliance & Patient Safety Manager (RCPSM), the VPBHC and RCPSM stated the following. On 7/28/2023, a patient (Patient 1) attempted to hang himself by wrapping a bedsheet around his neck and attaching the bedsheet between the gap of the shelving unit (or dresser) and the wall. Patient 1 was given CPR and transferred to the Emergency Department (ED). Patient 1 was intubated (a tube is inserted through a person ' s mouth or nose and into the airway to keep, to keep the airway open) and transferred to the Intensive Care Unit (ICU). The VPBHU stated that after the incident, there was a delay in closing the gaps between the shelving units and the wall because the VPBHU was unsure as to whether to remove the shelving unit or place brackets on the dressers to remove the gap. The first "L" - shaped bracket (channel) was installed today (9/18/2023). The VPBHU and the RCPSM acknowledged the delay in closing the gaps had the posed a ligature risk for patients in the BHU.

During an interview, on 9/19/2023 at 1:15 p.m., the RCPSM stated that all 24 patients in the BHU were at risk for self-harm.

During a review of Patient 1's "Inpatient Face sheet," the Face Sheet indicated Patient 1 was admitted to the facility on 7/28/2023 for depressive disorder (or depression, depressed mood or loss of pleasure or interest in activities for a long period of time).

During a review of Patient 1's Emergency Department (ED) note titled "HPI (history of present illness) ED General," dated 7/28/2023 at 12:46 a.m., the ED note indicated Patient 1 had a past medical history of "bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression, brought in by the police department for a 5150 (72-hour) hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for suicidal (intentionally taking your own life) gesture tonight ...Patient 1 has self-inflicted neck abrasion and bilateral wrist lacerations (cuts)."

During a review of Patient 1's "Nursing Shift Assessment," dated 7/28/2023, the assessment indicated Patient 1 was on a 5150 hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for danger to self.

During a review of Patient 1's "Code Blue (indicated a patient requiring resuscitation [reviving] or in need of immediate medical attention) Record" dated 7/28/2023, the record indicated Patient 1 was in his (Patient 1) room. Patient 1 was unconscious, no breaths and no pulse. Chest compressions (the act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation) started at 2:32 p.m. Bag-valve-mask ventilation (use of a hand-held tool to deliver positive pressure ventilation [process of air flowing into the lungs and out of the lungs] to a patient with insufficient or ineffective breaths) started at 2:33 p.m. Patient 1 was resuscitated (revive from unconsciousness or apparent death) and transferred to the ED at 2:40 p.m.

During a review of Patient 1's nurses note, dated 7/28/2023 at 2:54 p.m., the note indicated at 2:30 p.m., Patient 1 was found in his room with a wet blanket around his neck. The blanket was "dugged-in (burying)" behind the drawer. CPR started. Code blue was called. Response team came. Patient 1 was transferred to ED.

During a review of the Patient 1's ED note titled "History of Present Illness - ED General," dated 7/28/2023 at 2:57 p.m., the ED Note indicated the following: "Chief complaint: Cardiac arrest (heart stopped)/CPR. Patient 1 was in the BHU. There was a code blue called ...Patient 1 was on the floor in his room, CPR was in progress. Staff there said Patient 1 was found with a sheet around his neck. The staff started CPR immediately after Patient 1 was found and noted to have no pulse ...Patient 1 regained a pulse, was given supplemental oxygen and immediately brough to the ED. Procedures: Rapid Sequence Intubation (a technique that is used when a rapid control of the airway is needed as a precaution for a patients that may have risk of pulmonary aspiration [a condition in which food, liquid, saliva, or vomit is breathed into the airway])."

During a concurrent interview and record review, on 9/18/2023 at 4:03 p.m. with the UM 1 and the Quality Review Nurse (QRN) 5, the UM 1 and QRN 5 verified that Patients 2, 3, 4, 5, 6, and 7, were at risk for self-harm.

During a review of Patient 2's "Inpatient Face sheet," the face sheet indicated Patient 2 was admitted to the facility on 9/13/2023 for unspecified psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them).

During a review of Patient 2's "Psychiatry (specializes in mental health)- H&P (History & Physical, the most formal and complete assessment of the patient and the problem)," dated 9/14/2023, the "H&P" indicated the following: Diagnosis included psychosis, danger to self (DTS)/gravely disabled (GB, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs). Patient 2 was brought by ambulance from outside hospital on a 5150 hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for DTS, "reporting suicidal ideation (SI) to run into traffic ...Patient 2 is currently stating he is going to go to his room and hang himself ..."

During a review of Patient 3's "Inpatient Face sheet," the face sheet indicated Patient 3 was admitted to the facility on 9/16/2023 for unspecified psychosis (when people lose some contact with reality).

During a review of Patient 3's "Psychiatry - H&P (History and Physical, the most formal and complete assessment of the patient and the problem)," dated 9/17/2023, the "H&P" indicated the following: "Diagnosis included psychosis, DTS - unstable. Patient 3 with a past medical history (PMHx) of anxiety (intense, excessive, and persistent worry and fear about everyday situations), was brought by ambulance from home to ED for evaluation of a panic attack (a brief episode of intense anxiety). Patient 3 does endorse SI without a plan."

During a review of Patient 4's "Inpatient Face sheet," the face sheet indicated Patient 4 was admitted to the facility on 9/14/2023 for depressive disorder (or depression, depressed mood or loss of pleasure or interest in activities for a long period of time).

During a review of Patient 4's "Psychiatry - H&P," dated 9/15/2023, the "H&P" indicated the following. "Diagnosis: Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), DTS (Danger to Self). Patient 4 was brought in by ambulance from home for evaluation of suicide attempt via hanging ..."

During a review of Patient 5's "Inpatient Face sheet," the face sheet indicated Patient 5 was admitted to the facility on 9/16/2023 for unspecified psychosis (when people lose some contact with reality).

During a review of Patient 5's "Psychiatry (specializes in mental health)- H&P," dated 9/16/2023, the "H&P" indicated the following. Diagnosis: psychosis, DTS/ DTO (danger to others). Patient 5 was brought in by the police department (PD) on a 5150 - hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) danger to self, due to dancing in traffic, placing himself at risk. Per hold, Patient 5 was also tightening a string around his neck when he was talking to the police.

During a review of Patient 6's "Inpatient Face sheet," the face sheet indicated Patient 6 was admitted to the facility on 9/17/2023 for unspecified psychosis.

During a review of Patient 6's "Psychiatry - H&P," dated 9/17/2023, the "H&P" indicated the following. "Diagnosis: psychosis, schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), DTS/GD (Grave Disability) - unstable ...Patient 6 was brought in by ambulance from the mall ...on presentation to the Emergency Room, Patient 6 tell provider that he is suicidal and that he plans to run out into traffic or cut his wrist and has had previous suicide attempts."

During a review of Patient 7's "Inpatient Face sheet," the face sheet indicated Patient 6 was admitted to the facility on 9/07/2023 for depressive disorder.

During a review of Patient 7's "Psychiatry - H&P," dated 9/08/2023, the "H&P" indicated the following. "Diagnosis: psychosis, DTS/GD (Grave Disability) ...Patient 7 with a past medical history (PMH) of bipolar disorder, schizophrenia ...was brought in by ambulance for evaluation of multiple complaints ...Patient 7 reports suicidal ideation and paranoid thoughts people are after him. Patient 7 notes hearing voices telling him to kill himself by jumping in front of a truck."

During a review of a document titled, "Request Work Order," dated 8/14/2023, the work order indicated the following: "Location: BHU. Priority: 1 - Emergency/Safety. Requested Remarks: Metal plates around dressers must be completed asap (as soon as possible). Incident occurred on unit." Completion by (signature of the person who filled out the Request Work Order) and date (when the facility personnel signed the Request Work Order form) was blank.

During a review of the facility's policy and procedure (P&P) titled, "Contraband Items (prohibited items) #200.07," dated 5/2023, the P&P indicated the BHU will provide and maintain a safe environment at all times.

During a review of the facility's undated "Suicide & Ligature Risk Assessment," the assessment indicated CMS (Centers for Medicare and Medicaid) defines ligature as "Anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation."

2. During an observation on 9/18/2023 beginning at 12:10 p.m., the following was observed in the Behavioral Health Unit (BHU). Four of 15 patient rooms (for Patients 2, 3, 4, 5, 6, and 7) in the BHU had ½ to 1-inch gaps between the electrical conduits (a tube used to protect and route electrical wires within a structure) and the wall located above the wall light, which could be used as an anchor point for ligature.

During a concurrent interview, on 9/18/2023 at 12:10 p.m., with the SPO, the SPO acknowledged that the gaps between the electrical conduits (a tube used to protect and route electrical wires within a structure) and the wall posed a ligature risk and stated, "we need to close that off."

During a concurrent interview and record review, on 9/18/2023 at 4:03 p.m. with the Unit Manager (UM) 1 and Quality Review Nurse (QRN) 5, the UM 1 and QRN 5 verified that Patients 2, 3, 4, 5, 6, and 7, were at risk for self-harm.

During a review of Patient 2's "Inpatient Face sheet," the face sheet indicated Patient 2 was admitted to the facility on 9/13/2023 for unspecified psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them).

During a review of Patient 2's "Psychiatry - H&P (History & Physical, the most formal and complete assessment of the patient and the problem))," dated 9/14/2023, the "H&P" indicated the following: "Diagnosis included psychosis, danger to self (DTS) / gravely disabled (GB, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs) - unstable. Patient 2 was brought by ambulance from outside hospital on a 5150 hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for DTS, reporting suicidal ideation (SI, thoughts of killing oneself) to run into traffic ...Patient 2 is currently stating he is going to go to his room and hang himself ..."

During a review of Patient 3's "Inpatient Face sheet," the face sheet indicated Patient 3 was admitted to the facility on 9/16/2023 for unspecified psychosis.

During a review of Patient 3's "Psychiatry - H&P," dated 9/17/2023, the "H&P" indicated the following: "Diagnosis included psychosis, DTS - unstable. Patient 3 with a past medical history (PMHx) of anxiety (intense, excessive, and persistent worry and fear about everyday situations), was brought by ambulance from home to ED for evaluation of a panic attack (a brief episode of intense anxiety). Patient 3 does endorse SI without a plan."

During a review of Patient 4's "Inpatient Face sheet," the face sheet indicated Patient 4 was admitted to the facility on 9/14/2023 for depressive disorder.

During a review of Patient 4's "Psychiatry - H&P," dated 9/15/2023, the "H&P" indicated the following. "Diagnosis: Bipolar, DTS. Patient 4 was brought in by ambulance from home for evaluation of suicide attempt via hanging ..."

During a review of Patient 5's "Inpatient Face sheet," the face sheet indicated Patient 5 was admitted to the facility on 9/16/2023 for unspecified psychosis.

During a review of Patient 5's "Psychiatry - H&P," dated 9/16/2023, the "H&P" indicated the following. "Diagnosis: psychosis, DTS / DTO (danger to others). Patient 5 was brought in by the police department (PD) on a 5150 - hold danger to self, due to dancing in traffic, placing himself at risk. Per hold, Patient 5 was also tightening a string around his neck when he was talking to the police."

During a review of Patient 6's "Inpatient Face sheet," the face sheet indicated Patient 6 was admitted to the facility on 9/17/2023 for unspecified psychosis.

During a review of Patient 6's "Psychiatry - H&P," dated 9/17/2023, the "H&P" indicated the following. Diagnosis: psychosis, schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), DTS / GD - unstable ...Patient 6 was brought in by ambulance from the mall ...on presentation to the Emergency Room, Patient 6 tell provider that he is suicidal and that he plans to run out into traffic or cut his wrist and has had previous suicide attempts.

During a review of Patient 7's "Inpatient Face sheet," the face sheet indicated Patient 6 was admitted to the facility on 9/07/2023 for depressive disorder.

During a review of Patient 7's "Psychiatry - H&P," dated 9/08/2023, the "H&P" indicated the following. "Diagnosis: psychosis, DTS / GD ... Patient 7 with a past medical history (PMH) of bipolar disorder, schizophrenia ...was brought in by ambulance for evaluation of multiple complaints ...Patient 7 reports suicidal ideation and paranoid thoughts people are after him. Patient 7 notes hearing voices telling him to kill himself by jumping in front of a truck."

During a review of the facility's policy and procedure titled, "Contraband Items #200.07," dated 5/2023, indicated the BHU will provide and maintain a safe environment at all times.

During a review of the facility's undated "Suicide & Ligature Risk Assessment," the assessment indicated CMS (Centers for Medicare and Medicaid) defines ligature as "Anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation."

3. During an observation on 09/18/2023 at 1:20 p.m. in Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), Clinical Nurse Partner (CNP) 1 conducted rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) and peeked through the windows in three of three patient rooms. Room doors were closed. CNP 1 did not enter the rooms.

During an interview on 09/18/2023 at 1:28 p.m. with CNP 1, CNP 1 stated, "I have to get in the rooms every 15 mins." CNP 1 also stated "after lunch I did not go into the room. I just look through the window."

During an interview on 09/18/2023 at 1:38 p.m. with unit manager (UM)1. UM 1 stated CNPs made rounds to check the environment and to look at what patients were doing. The CNPs would make sure there was no contraband (prohibited items such as knives, etc.) in the room. UM 1 stated "they are required to go into the room. Open the door and check."

During an interview on 09/18/2023 at 3:12 p.m. with Vice President of Behavioral Health Unit (VPBHU), VPBHU stated when conducting the rounding, staff should walk into the room all the way to the shower room because something could be broken in the restroom and there could be environmental hazards. VPBHU also stated it was important to go into the room and check because someone could have passed out and/or doing something inappropriate in the room.

During a review of the facility's policy and procedure (P&P) titled, "Patient Observation #100.15 (unit rounding)," dated 1/20/2023, the P&P indicated "patient rounding is done using acute observation. Acute observation (rounding) is performed on the unit as a tool to ensure patient and environmental safety ...Rounding at regular intervals is designed to ensure that each patient is observed by a staff member who can quickly assess the patient's overall condition and then raise alerts if the patient's status has changed significantly or if a safety concern is noted in the environment. Staff will visualize and listen for signs of distress, and if possible, briefly converse with each patient on each round to assess for indicators of safety/medical needs, behavior / mood/thought changes, and current activity ...Environmental and safety checks are also conducted on each round."

4. During an observation on 09/19/2023 at 11:04 a.m. in critical care unit (provides medical care for patients with life-threatening conditions or illnesses), there were two crash carts (a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment) in the nursing station next to each other. Both crash carts were missing Ambu Bags (a device to provide respiratory support).

During an interview on 09/19/2023 at 11:19 a.m. with charge nurse (CN) 1, CN 1 stated Ambu Bags should be with the crash cart. Ambu Bags were needed for emergencies.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Cart-Code Cart Maintenance - ICH/QVH #EC-140," dated 01/2023, the P&P indicated, "Equipment, supplies and medications usually required to treat a life-threatening situation, such as cardiac and/or respiratory arrest (heart stopped) are maintained in an emergency cart for ready access on patient care areas."

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI-a process used to ensure services are meeting quality standards and assuring care reaches a certain level) was met as evidenced by:

1. The Quality & Performance Improvement department failed to ensure that data collected from environment of care (EOC, rounds to ensure safety of patients) rounding reports from the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) were accurate to ensure patient safety, after Patient 1 attempted to hang himself by attaching a bedsheet between the gap of the shelving unit (dresser) and wall and wrapping the bedsheet around his neck on 7/28/2023. This deficient practice resulted in inaccurate rounding reports and had the potential to compromise patients' safety in the BHU. (Refer to A - 0273)

2. The facility failed to ensure the root cause (the reason for the occurence of a problem) of an incident was corrected, after a patient (Patient 1) attempted to hang himself by wrapping a bedsheet around his neck and attaching the bedsheet between the gap of the shelving unit (dresser) and wall, in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency). This deficient practice compromised the safety of patients in the BHU. (Refer to A-0286)

3. The facility failed to ensure that it has a tracking system (monitoring process to improve decisions) for reporting unusual occurrences (uncommon occurrences outside the normal, such as poisonings, etc.) to the California Department of Public Health (CDPH) to assure compliance with regulatory standards with regards to reporting. The facility failed to report an unusual occurrence following the event that occurred on 8/2/2023, when Patient 16 was being transported from the intensive care unit (ICU, which provides continuous treatment for patients who are seriously ill) to a CT scan (Computerized tomography, a procedure using specialized equipment to produce cross-sectional images of the body for better visualization), in which the portable ventilator and the oxygen tank were not turned on (as stated by Imaging Assistants (AI)1 and AI 2 during interviews on 9/22/23 at 10:13 a.m.) for one of thirty sampled patients (Patient 16).

This deficient practice had the potential to result in delay of investigation and potentially placing patients at risk of not receiving necessary care and treatments. (Refer to A-0286)

The cumulative effect of these deficient practices had the potential to compromise patient safety.

Based on observation, interview, and record review, the Quality & Performance Improvement department failed to ensure that data collected from environment of care (EOC, rounds to ensure safety of patients) rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) reports from the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) were accurate for ligature risk assessment to ensure patient safety, after Patient 1 attempted to hang himself by attaching a bedsheet between the gap of the shelving unit (dresser) and wall and wrapping the bedsheet around his neck on 7/28/2023.

This deficient practice resulted in inaccurate rounding reports and had the potential to compromise patients ' safety in the BHU.

Findings:

During an observation on 9/18/2023 beginning at 12:07 p.m., in the Behavioral Health Unit (BHU), the following was observed. Fourteen (14) of 15 patient rooms had a ½ to 1-inch gap between the anchored wood shelving units (or dressers) and the wall. The gap could be used as an anchor point for ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). One (1) of 15 shelving units had a "L"- shaped bracket or channel attached to the top of the shelving unit, that closed the gap between the shelving unit and the wall. Twenty-three (23) patients occupied the affected rooms.

During an interview, on 9/18/2023 at 1:30 p.m., with Registered Nurse (RN) 1 and Unit Manager (UM) 1, RN 1 and UM 1 stated the following. Four to six weeks ago, an incident occurred where a patient (Patient 1) attempted to hang himself by attaching a bedsheet between the gap of the shelving unit and the wall and wrapping the bedsheet around his neck. Patient 1 was found unconscious by his roommate, who reported it to nursing staff. Nursing staff found Patient 1 in a sitting position in front of the shelving unit with the bedsheet wrapped around his neck. Patient 1 was given CPR (Cardiopulmonary resuscitation, a life-saving procedure performed when the heart stops beating), a code blue (indicated a patient requiring resuscitation [reviving} or in need of immediate medical attention) was called, and Patient 1 was transferred to the Emergency Department (ED- responsible for the administration and provision of immediate medical care to the patient upon the patient's arrival to the facility) for further evaluation.

During an interview on 9/22/2023 at 9:27 a.m., with the Corporate Director of Risk Management (CDRM), the CDRM verified that an incident of an attempted hanging occurred in the BHU on 7/28/2023. The CDRM stated an official Root Cause Analysis (RCA- a process for identifying the reason why an incident occurred) was conducted on 8/10/2023. The CDRM stated the RCA indicated the cause of the incident was the gap between the dresser and the wall.

During an interview on 9/22/2023 at 9:38 a.m., with Unit Manager (UM 1) for the Behavior Health Unit, UM 1 said the following. The gap between the shelving unit (dresser) and the wall was considered a ligature risk (or ligature point, anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation), after an incident of attempted hanging by Patient 1 on 7/28/2023. UM 1 stated environment of care (EOC) rounding tracer (process to validate the outcome of an intervention) was conducted by the unit manager twice a month. Item # 40 of the tracer addressed ligature risk assessment. UM 1 stated the EOC rounding tracers dated 8/4/2023 and 8/25/2023 were inaccurate because the gap between the shelving units and the wall still existed in the Behavioral Health Unit and posed a ligature risk for patients in the BHU.

During an interview on 9/22/2023 at 2:12 p.m. with the Director of Performance Improvement (DPI), the DPI verified that the "Behavior Health Unit Dashboard," dated 1/2023 to 8/2023 was inaccurate because the Environment of Care (EOC) rounding forms dated 8/4/2023 and 8/25/2023 that were submitted by the Behavioral Health Unit to the Quality & Performance Improvement Department did not reflect that there were ligature risks (referring to the gaps between the dressers and wall) in the Behavioral Health Unit.

During an interview on 9/22/2023 at 2:12 p.m. with the Chief Nurse Executive (CNE) 1, CNE 1 stated when environment of care (EOC) rounding reports indicate that a unit is 100 % in compliance, the information is usually validated to ensure it is done. CNE 1 did not indicate that the rounding tracer from the BHU had been validated for accuracy.

During a review of two (2) tracers (method for evaluating the system or process) in the Behavioral Health Unit titled "EOC Rounding Tracer," dated 8/4/2023 and 8/25/2023, completed by UM 1, the tracer indicated the following. The Unit Walk Around section indicated "to observe the area: There are NO environmental features (such as anchor points, door hingers, hooks) that could be used for suicide." The tracer indicated "Yes", meaning there were no such features present. No comments were documented under Follow-up/Plan of Action.

During a review of a report titled "Comprehensive Tracer Report - Summary By Questions," from 6/1/2023 to 9/22/2023, the report indicated the Behavioral Health Unit was 100 % compliant with Question 40: "Observe the area: There are NO environmental features (such as anchor points, door hinges, hooks) that could be used for suicide."

A review of a report titled "Behavior Health Unit Dashboard," dated 1/2023 to 8/2023, indicated the following. The BHU was 100 % complaint in 7/2023 and 8/2023 for the following: "The at-risk patient was placed in most appropriate setting (i.e., safe, monitored, and clear of items that the patient could use to their selves or others)."

A review of the facility's "2023 Performance Improvement Plan," indicated the purpose of the Quality Assessment and Improvement/ Patient Safety Committee (QA&I) is to ensure that opportunities to improve quality and patient safety was identified and action plans put in place.

Based on observation, interview, and record review, the facility failed to ensure:

1. The root cause (reason for the occurence of a problem) of an incident (presence of ligature risk [or ligature point, anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] in the patient rooms by the presence of gap between the shelving and the wall) was resolved as indicated on the work order, after a patient (Patient 1) attempted to hang himself by wrapping a bedsheet around his neck and attaching the bedsheet between the gap of the shelving unit (dresser) and wall, in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency). This deficient practice compromised the safety of patients in the BHU.

2. That it (the facility) has a tracking system (monitoring process to improve decisions) for reporting unusual occurrences (uncommon occurrences outside the normal, such as poisonings, etc.) to the California Department of Public Health (CDPH) to assure compliance with regulatory standards with regards to reporting. The facility failed to report an unusual occurrence following the event that occurred on 8/2/2023, when Patient 16 was being transported from the intensive care unit (ICU, which provides continuous treatment for patients who are seriously ill) to a CT scan (Computerized tomography, a procedure using specialized equipment to produce cross-sectional images of the body for better visualization), in which the portable ventilator and the oxygen tank were not turned on (as stated by Imaging Assistants (AI)1 and AI 2 during interviews on 9/22/23 at 10:13 a.m.) for one of thirty sampled patients (Patient 16).

This deficient practice had the potential to result in delay of investigation and potentially placing patients at risk of not receiving necessary care and treatments.

Findings:

During an observation on 9/18/2023 beginning at 12:07 p.m., in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency), the following was observed. Fourteen (14) of 15 patient rooms had a ½ to 1-inch gap between the anchored wood shelving units (or dressers) and the wall. The gap could be used as an anchor point for ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). One (1) of 15 shelving units had a "L"- shaped bracket or channel attached to the top of the shelving unit, that closed the gap between the shelving unit and the wall. Twenty-three (23) patients occupied the affected rooms.

During an interview on 9/18/2023 at 12:46 p.m., with the Supervisor of Plant Operations (SPO), the SPO stated the following. The "L" shaped bracket was put in place to anchor the shelving unit to close the gap between the shelving unit and the wall to prevent patients from hanging themselves. The SPO could not recall the exact date but stated an incident occurred over a month ago, where a patient (Patient 1) attempted to hang himself by attaching a bedsheet to the shelving unit and wrapped it around his neck. The SPO received a work order to place "L" channels (purpose is to close the identified gaps) on all shelving units in the BHU over a month ago. The SPO stated he just installed the first "L" bracket (channel) today (9/18/2023) because the SPO needed the materials to start the project. The SPO stated he had the materials onsite and just found the materials today (9/18/2023).

During an interview, on 9/18/2023 at 3 p.m. with the Vice President of the Behavioral Health Unit (VPBHU) and the Regulatory Compliance & Patient Safety Manager (RCPSM), the VPBHU and the RCPSM stated the following. On 7/28/2023, a patient (Patient 1) attempted to hang himself by wrapping a bedsheet around his neck and attaching the bedsheet between the gap of shelving unit (or dresser) and the wall. Patient 1 was given CPR (Cardiopulmonary resuscitation, a life-saving technique that is useful in emergencies when someone ' s breathing or heartbeat has stopped) and transferred to the Emergency Department (ED, responsible for the administration and provision of immediate medical care to the patient upon the patient ' s arrival to the facility). Patient 1 was intubated (a tube is inserted through a person ' s mouth or nose and into the airway to keep, to keep the airway open) and transferred to the Intensive Care Unit (ICU, which provides continuous treatment for patients who are seriously ill).

The VPBHU stated that after the incident, there was a delay in closing the gaps between the shelving units and the wall because the VPBHU was unsure as to whether to remove the shelving unit or place brackets on the dressers to remove the gap. The first "L" - shaped bracket (channel) was installed today (9/18/2023). The VPBHU and the RCPSM acknowledged the delay in closing the gaps had posed a ligature risk (or ligature point, anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) for patients in the BHU.

During a concurrent interview and record review, on 9/18/2023 at 4:03 p.m. with the Unit Manager (UM) 1 and Quality Review Nurse (QRN) 5, the UM 1 and QRN 5 stated that all 24 patients in the BHU were at risk of self-harm.

During an interview on 9/20/2023 at 9:31 a.m. with the Regulatory Compliance & Patient Safety Manger (RCPSM), the RCPSM stated the following. A root cause analysis (RCA, a process for identifying the reason why an incident occurred) was performed to identify the cause of the incident (Patient 1 attempted hanging on 7/28/2023) and discussed different options to resolve the cause to prevent recurrence. The gap between the wall and the dresser was identified as a ligature risk, however, the issue was not resolved. The corrective action was not firmly executed. The corrective action should have been expedited. The execution did not occur in a timely manner.

During an interview on 9/21/2023 at 1:45 p.m. with SPO and the Assistant Director of Plant Operations (ADPO), the SPO and ADPO stated Patient 1 attempted to hang himself on 7/28/2023. SPO and ADPO received a work order on 8/14/2023 to place metal plates around the dressers in the BHU and must be completed ASAP (as soon as possible). The SPO and ADPO stated the request ' s priority was "Priority 1," meaning it was top priority and should be completed within 1 - 2 days. The SPO stated the first metal plate was placed on 9/18/2023.

During an interview on 9/21/2023 at 2:30 p.m. with the Director of Performance Improvement (DPI), the DPI stated there was clearly a delay in closing the gaps between the wall and the dressers in the BHU.

During an interview on 9/22/2023 at 9:27 a.m. with the Corporate Director of Risk Management (CDRM), the CDRM verified that an incident of an attempted hanging occurred in the BHU on 7/28/2023. The CDRM stated an official RCA was conducted on 8/10/2023. The CDRM said the RCA indicated the cause of the incident was the gap between the dresser and the wall. The action plan indicated to use metal plates to cover the gaps.

During a review of Patient 1's "Inpatient Face sheet," the Face Sheet indicated Patient 1 was admitted to the facility on 7/28/2023 for depressive disorder (or depression, depressed mood or loss of pleasure or interest in activities for a long period of time).

During a review of Patient 1's Emergency Department (ED) note titled "HPI (history of present illness) ED General," dated 7/28/2023 at 12:46 a.m., the Emergency Department Note indicated Patient 1 had a past medical history of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression, brought in by the police department for a 5150 (72-hour) hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for psychiatric [mental health] hospitalization) for suicidal (intentionally taking your own life) gesture tonight ...Patient 1 has self-inflected neck abrasion and bilateral wrist lacerations (cuts).

During a review of Patient 1's nurses note, dated 7/28/2023 at 2:54 p.m., the note indicated at 2:30 p.m., "Patient 1 was found in his room with a wet blanket around his neck. The blanket was "dugged-in (burying)" behind the drawer. CPR started. Code blue (indicated a patient requiring resuscitation [reviving] or in need of immediate medical attention) was called. Response team came. Patient 1 was transferred to ED."

During a review of a document titled, "Request Work Order," dated 8/14/2023, the work order indicated the following: Location: BHU. Priority: 1 - Emergency/ Safety. Requested Remarks: Metal plates around dressers must be completed asap (as soon as possible). Incident occurred on unit. The completion by (signature of the person who filled out the Request Work Order) and date (of when the Request Work Order was made) was blank.

2. During an interview on 9/19/2023 at 3:28 a.m. with the Corporate Director of Risk Management (CDRM), the CDRM stated the following: The event that occurred on 8/2/2023, where Patient 16's portable ventilator (a machine that helps a patient breathe) and oxygen tank were not turned on, was not reported to the state agency. CDRM stated the event has not been presented to the Quality Performance Improvement Committee (QPIC, a process used to ensure services are meeting quality standards and ensuring care reaches a certain level) meetings because she (the CDRM) was on PTO (Personal Time Off). CDRM stated that the Assistant Director of Respiratory Care Services is a standing member of the QPIC meeting, but she is not sure that he attended the last meetings. CDRM further stated, "Respiratory does not present in the meeting; it would be me."

During a concurrent interview and record review on 9/22/2023 at 1:41 p.m. with CDRM, the facility's QPIC meeting's agenda titled "Quality Performance Improvement Committee: Agenda," dated August 16, 2023, was reviewed. CDRM stated she would have presented at the meeting, but her presentation was not about the event that occurred on 8/2/2023. CDRM pointed to the agenda and stated that if the incident had been presented, it would fall under the presentation by the Chief Medical Officer.

During an interview on 9/22/2023 at 2:12 p.m. with the Chief Medical Officer (CMO), the CMO stated, "This incident (on 8/2/2023, when Patient 16's ventilator and oxygen were reported by witness staff to not be turned on and Patient 16's heart rate dropped and eventually went into cardiac arrest and died) was not brought up in the QPIC meeting on 8/16/2023.

During a review of the facility's policy titled, "Sentinel Events (a patient safety event that results in death, permanent harm, or severe temporary harm)," revision date 12/2022, the policy indicated the following. Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, close calls, and hazardous conditions, which are defined as follows:

1. Adverse Event: A patient safety event that resulted in harm to a patient.

2. No-harm Event: A patient safety event that reaches the patient but does not cause harm.

3. Close Call: A patient safety event that did not reach the patient (also referred to as a "good catch.)"

Permanent harm: An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual's baseline health ...The facility respond to each sentinel event and serious event requiring intensive analysis by engaging in a root cause analysis and process improvement to reduce the likelihood of recurrence of a similar event in the future. A sentinel event may be identified through the quality care or risk management alert systems, including the electronic incident reporting system, the Chief Medical Officer (CMO), and/or the Chief Nursing and Clinical Executive (CNCE) of the specific campus based on correspondence or reports from patients or external agencies ..."

During a review of the facility's policy titled, "Reporting Adverse Events to California Department of Public Health," revision date 4/2021, the policy indicated the following. "Any adverse event that causes death or serious disability of patients, personnel or visitors will be reported to the local office of California Department of Public Health (CDPH) within five days after the event has been detected. Events that have ongoing urgent or emergent threat to the welfare, health or safety of patients, personnel or visitors will be reported within twenty-four hours ..."

Based on observation, interview, and record review the facility failed to ensure one of two Clinical Nurse Partners (CNP 1) conducted proper rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) in three (3) of 3 patient rooms in the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with a mental health emergency) by peeking through the windows instead of entering the patients ' rooms to check for patient safety and environmental hazards.

This failure had the potential to result in patients keeping contraband (prohibited items) and staff not identifying ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in the room.

Findings:

During an observation on 09/18/2023 at 1:20 p.m. in Behavioral Health Unit (BHU), CNP 1 conducted rounding (best practice interventions to routinely meet patient care needs and ensure patient safety) and peeked through the windows in three of three patient rooms. Room doors were closed. CNP 1 did not enter the rooms.

During an interview on 09/18/2023 at 1:28 p.m. with CNP 1, CNP 1 stated, "I have to get in the rooms every 15 mins." CNP 1 also stated "after lunch I did not go into the room. I just look through the window."

During an interview on 09/18/2023 at 1:38 p.m. with unit manager (UM)1. UM 1 stated CNPs made rounds to check the environment and to look at what patients were doing. The CNPs would make sure there was no contraband in the room. UM 1 stated "they are required to go into the room. Open the door and check."

During an interview on 09/18/2023 at 3:12 p.m. with Vice President of Behavioral Health Unit (VPBHU), VPBHU stated when conducting the rounding, staff should walk into the room all the way to the shower room because something could be broken in the restroom and there could be environmental hazards. VPBHU also stated it was important to go into the room and check because someone could have passed out and/or doing something inappropriate in the room.

During a review of the facility ' s policy and procedure (P&P) titled, "Patient Observation #100.15 (unit rounding)," dated 1/20/2023, the P&P indicated patient rounding is done using acute observation. "Acute observation (rounding) is performed on the unit as a tool to ensure patient and environmental safety ...Rounding at regular intervals is designed to ensure that each patient is observed by a staff member who can quickly assess the patient ' s overall condition and then raise alerts if the patient ' s status has changed significantly or if a safety concern is noted in the environment. Staff will visualize and listen for signs of distress, and if possible, briefly converse with each patient on each round to assess for indicators of safety/medical needs, behavior/mood/thought changes, and current activity ...Environmental and safety checks are also conducted on each round."

Based on observation and interview the facility failed to maintain the environment in a manner that the safety and well-being of the patients are assured by having potential ligature anchors. This deficient practice had the potential to compromise patient safety.

Findings:

1. On 09/18/2023 at 12:13 p.m. the evaluator observed 4 of 15 Behavioral Health Unit rooms (Rooms 150, 160, 163, and 164) had gaps behind electrical conduits and the walls where the conduits could be used as anchor points for ligature. The conduits went from the ceilings to the wall mounted light fixtures.

Closer observation revealed there were bed side tables that could be climbed on to reach the gaps behind electrical conduits and walls.

During a concurrent interview the Supervisor of Plant Operations stated the new light fixtures were installed around six months ago.


2. On 09/18/2023 at 12:13 p.m. the evaluator observed new wall lights installed in 15 of 15 Behavioral Health Unit rooms.

During a concurrent interview the Supervisor of Plant Operations stated the new light fixtures were installed around six months ago.

At this time the evaluator requested the HCAI approvals for the installation of the new wall mounted light fixtures form the Supervisor of Plant Operations.

The Supervisor of Plant Operations stated he did not know if HCAI approvals were obtained for the installation of the new wall lights, and that the Assistant Director of Plant Operations would know if the light fixtures were installed with HCAI approvals.

At 3:30 p.m. the evaluator requested the HCAI approvals for the installation of the new wall mounted light fixtures from the Assistant Director of Plant Operations

No documented evidence of HCAI approvals for new wall light fixtures

3. On 09/18/2023 at 12:21 p.m. the evaluator observed an Emergency exit corridor from the Behavioral Health Unit was obstructed by items stored in the corridor that included a rolling ladder, a five foot long steel wall edging, extension cord on the floor, table and chairs.

During a concurrent interview the Vice President of the Behavioral Health Unit stated that the patients of the Behavioral Health Unit would be evacuated through the emergency exit in the event of an emergency evacuation.

4. On 09/18/2023 at 12:30 p.m. the evaluator observed a thermostat cover plate pulled away from the wall in room 160 of the Behavioral Health Unit.

During a concurrent interview the Supervisor of Plant Operations acknowledged the cover plate was pulled away.

5. On 09/18/2023 at 12:43 p.m. the evaluator observed 14 of 15 Behavioral Health Unit rooms (Rooms 150, 151, 152, 153, 155, 156, 157, 158, 159, 160, 161, 162, 163, and 164) had gaps behind dressers and the walls where the dressers could be used as anchor points for ligature.

The gap behind the dresser in room 163 was 1 ½ - inches.

Closer observation revealed the dresser in one of the rooms had a metal plate placed over the gap.

During a concurrent interview the Supervisor of Plant Operations acknowledged the gaps and stated the metal plate had been installed across the gap of one of the dressers that morning to prevent hangings, that an incident had previously occurred and that he had not installed the metal plates over the gaps of the other dressers because he had just that morning found the material (metal plates).

At 3:09 p.m. the Behavioral Health Unit Manager stated that it (gap) should be covered because they (patients) can put something there, it's (dresser) strong enough maybe they can hang.

6. On 09/18/2023 at 1:10 p.m. the evaluator observed a loose sharps container with exposed anchors in the Treatment Plan Room of the Behavioral Health Unit.

During a concurrent interview the Supervisor of Plant Operations acknowledged the loose sharps container.

7. On 09/18/2023 at 1:22 p.m. the evaluator observed a loose electrical receptacle and cover plate in the kitchen of the Behavioral Health Unit.

During a concurrent interview the Supervisor of Plant Operations acknowledged the loose electrical receptacle and cover plate.

8. On 09/18/2023 at 1:30 p.m. the evaluator observed a ¼ - inch by 4 foot gap between the glazing and frame of a non-functioning sliding door at the interior dining area of the Behavioral Health Unit.

During a concurrent interview the Supervisor of Plant Operations acknowledged the gap at the sliding door.

Based on observation and interview, a portable ventilator was not maintained. This had the potential to compromise patient safety.

Findings:

On 09/19/2023 at 3:05 p.m. the evaluator observed portable ventilator serial number 1803100 was missing the Relief/Alarm Pressure knob and the Demand CMV/Demand knob. The frequency knob's cap and body indicators were misaligned with each other. The cap indicator of the knob was aligned at 15 breaths per minute (b/min) and body indicator of the knob was aligned at 20 b/min, a difference of 5 b/min.

On 09/19/2023 at 3:23 p.m. the Respiratory Care Supervisor stated that the Relief/Alarm Pressure settings detect if pressure is too high in the patients lungs and stops a breath provided by the ventilator, to drop the pressure and then continues to provide breaths. That the Demand CMV/Demand is the on/off button. That the misaligned 5 b/min misalignment would cause a patient to breath faster or slower and the severity of the outcome would depend on the condition of the patient, and that when the buttons are missing the ventilator should not be in use and taken off the floor.

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Respiratory Services were followed as evidenced by:

1. Portable ventilator (a machine that helps a patient breathe) did not have broken knobs (knobs used to control mechanical breath and affect alarm settings) when used to transport one of 30 sampled patients (Patient 16) who required mechanical ventilation (process of air flowing into the lungs and out of the lungs). This deficient practice had the potential to affect the ability to regulate various settings (Ventilator settings - used to control how much air is delivered into the patient's lungs) crucial for maintaining the patient's (Patient 16) respiratory function, hinder the accuracy of readings, delay detection of critical changes in patient's condition, and compromise patient safety. (Refer to A - 1152)

2. Failure to follow manufacturer user's manual and failure to provide written policies for respiratory care services that are developed for the preventative maintenance for two of two sampled portable ventilator equipment. This deficient practice had the potential to affect alarm function and cause inaccurate settings of ventilation that can potentially harm the patient's respiratory system, lead to oxygen deprivation, and cause respiratory distress (difficulty breathing). The facility continued to use a portable ventilator with two missing knobs after an incident on 8/02/2023 involving a patient whose portable ventilator was not turned-on during patient transport from the ICU (Intensive Care Unit, which provides continuous treatment for patients who are seriously ill). Refer to A - 1160)

3. Failure to ensure the respiratory care services (Ventilator settings - used to control how much air is delivered into the patient's lungs) ordered were documented in the medical record of one of the 30 sampled patients (Patient 16). This deficient practice had the potential to result in miscommunication between healthcare providers, which can lead to treatment errors or incorrect ventilator settings, putting the patient at risk of receiving inappropriate or potentially harmful care. (Refer to A-1164)

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality healthcare in a safe environment.

Based on observation, interview, and record review, the facility failed to provide a portable ventilator without missing knobs (knobs used to control mechanical breath and affect alarm settings) to transport one of 30 sampled patients (Patient 16) who required mechanical ventilation (process of air flowing into the lungs and out of the lungs with assistance of an equipment).

This deficient practice had the potential to affect the ability to regulate various settings crucial for maintaining the patient's (Patient 16) respiratory function, hinder the accuracy of readings, delay detection of critical changes in patient's condition, and compromise patient safety.

Findings:

During an interview on 9/19/2023 at 3:45 p.m. with the Supervisor of Respiratory Care Services (SRCS) in the respiratory supply room, SRCS stated, the portable ventilator (a machine that helps a patient breathe), "It should have been received with the knobs on the machine. It (knobs) went missing." SRCS confirmed that with knobs missing, it does not indicate which direction the knob is facing. SRCS explained that some of the function of the knobs control was adjustment of the breaths delivered by the ventilator which can cause the patient to breath faster or slower. SRCS stated, "It (adjusting the knobs) can affect the condition of the patient." SRCS stated he is unsure how long the knobs have been missing. SRCS further stated, "If the buttons (knobs) are missing the vent (ventilator) should be removed from service."

During a concurrent observation and interview on 9/19/2023 at 3:55 p.m. with the Manager of Biomed Engineering (MBM), the portable ventilator with two missing knobs was brought in for observation. It was confirmed with MBM that the missing knobs come with a line on top of the knobs to indicate the direction the knob is switched to. MBM acknowledged that missing knobs inhibit the manufacture intended function. MBM stated the portable ventilator should be returned to Biomed if there are missing knobs. MBM stated, "The portable ventilator with missing knobs has not been turned in to the biomed department (responsible for the smooth functioning of medical equipment/devices in the hospital)."

During a concurrent interview and record review on 9/22/2023 at 10:45 a.m. with SRCS, the portable ventilator user's manual was reviewed. After SRCS read the user's manual, SRCS stated, "I am not aware of that we would need to keep a maintenance log. We've only been cleaning it. I have not read the user ' s manual." SRCS stated for machine checks, it would be the supervisor ' s responsibility to establish daily and end of the month check.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Service or Care," last revised dated 3/2023, the P&P indicated the following. Respiratory Care is a life-supporting, life-enhancing health care profession practiced under qualified medical direction... Other services related or concomitant to respiratory care include cardiopulmonary resuscitation (CPR, a life-saving technique that is useful in emergencies when someone ' s breathing or heartbeat has stopped), quality assurance monitoring and evaluation, quality control, transporting critically ill patients to or from the hospital, maintaining and repairing equipment, documentation and continuing education... These are within the purview of other department's quality assurance programs (proactive and preventive activities focused on safe patient care). Scope or Services Offered By Respiratory or Pulmonary Department:

Ventilation Assistance

1. Emergency resuscitation (CPR) to include manual ventilation

2. Mechanical ventilation (process of air flowing into the lungs and out of the lungs with assistance of an equipment), including volume and pressure ventilators (a mode of ventilation in which the ventilator attempts to achieve set tidal volume [the amount of air that moves in or out of the lungs with each respiratory cycle] at lowest possible airway pressure)...Equipment

1. Evaluation

2. Maintenance

3. Modification

4. Calibration ...

Based on observation, interview, and record review the facility failed to follow manufacturer user's manual regarding the use and maintenance of a portable ventilator (a machine that helps a patient's lungs work) and failed to provide written policies for respiratory care services that are developed for the preventative maintenance for two of two sampled portable ventilator equipment.

This deficient practice had the potential to affect alarm function and cause inaccurate settings of ventilation that can potentially harm the patient's respiratory system, lead to oxygen deprivation, and cause respiratory distress (difficulty breathing). The facility continued to use a portable ventilator with two missing knobs after an incident on 8/02/2023 involving a patient (Patient 16) whose portable ventilator was not turned-on during patient transport from the ICU (Intensive Care Unit, which provides continuous treatment for patients who are seriously ill).

Findings:

During a concurrent observation and interview on 9/19/2023 at 9:45 a.m. with the Supervisor of Respiratory Care Services (SRCS) in the respiratory supply room, SRCS stated, "The second portable ventilator had been taken out of the rotation since the last time that you (the surveyor) were here (on 9/8/2023)." SRCS stated, "no one brought up knobs were missing from the portable ventilator until after the incident (on 8/2/23, when Patient 16's ventilator and oxygen were reported by witness staff to not be turned on and Patient 16's heart rate dropped and eventually went into cardiac arrest and died).

During a follow up interview on 9/19/2023 at 3:45 p.m. with SRCS, SRCS explained that the knobs missing were used to toggle between "Demand" and "CMV (Continuous Mandatory Ventilation, all of a patient's breaths are provided by a ventilator)/Demand," which SRCS stated, "Acts like the On and Off button," it provides controlled mandatory ventilation (process of air flowing into the lungs and out of the lungs with assistance of an equipment) to non-breathing patients and also activates the alarm but switching back to "Demand (regulates the airflow to meet the exact need)" will switch off the alarm. The second missing knob controls the pressure (causes the gas to flow into the lungs until the ventilator breath is terminated).

During a concurrent observation and interview on 9/19/2023 at 3:55 p.m. with Manager of Biomed Engineering (MBM), the portable ventilator with two missing knobs was brought in for observation. It was confirmed with MBM that the missing knobs come with a line on top of the knobs to indicate the direction the knob is switched to. MBM acknowledged that missing knobs inhibit the manufacture intended function. MBM stated the portable ventilator should be returned to Biomed if there are missing knobs. MBM stated, "The portable ventilator with missing knobs has not been turned in to the biomed department (responsible for the smooth functioning of medical equipment/devices in the hospital)." MBM also stated he will provide a copy of the facility policy for maintenance of respiratory loaner equipment and the manufacturer user's manual.

During a review of the facility's policy and procedure (P&P) titled, "Equipment, (Medical), Handling of Loaner, Rental, Demo or Trial," last revised dated 4/2018, the P&P indicated, "All rental, loaner, demo or non-hospital medical equipment brought into this facility must be properly processed by the Biomedical Department and receive a safety inspection prior to use ...During normal business hours, Nursing or Sterile Processing Department (SPD) or Central Services(CS) staff will notify the Biomedical Engineer by phone and submitting a work order via the intranet on the tab labeled" Biomed/Plant Ops Work Orders." Under the section called Biomed Repairs, select your campus/Biomed Repair. Complete the following fields:

a. Enter or Select Dept.

b. Location

c. Priority

d. Asset#- (Put in the campus and the word Rental ..."

During a concurrent interview and record review on 9/22/2023 at 9:53 a.m. with the MBM, the portable ventilator user manual was reviewed. Section 6 of the user manual indicated, "It is recommended that maintenance be carried out at two levels. At the first level, the procedure specified in Section should be followed on a regular interval, typically once a month, irrespective of use, and a record kept by the use of the log sheet at the back of this manual. At a second level, the performance of the ventilator should be checked." MBM stated the second level of maintenance recommended is the part he explained earlier, which requires service no more than every six months but at least once every two years. The first level of maintenance stated MBM, "We don't do preventative maintenance on rentals. The monthly check should be done by the respiratory department." After reading the maintenance, regarding monthly checks of the portable ventilator rental, MBM stated, "I am aware they should be doing this." Each unit generally orders equipment they are familiar with; it is up to the individual department to perform their own equipment checks. Biomed would not give directives for monthly equipment checks. Service schedule is done by the rental company."

During a concurrent interview and record review on 9/22/2023 at 10:45 a.m. with SRCS, the portable ventilator user's manual was reviewed. After SRCS read the user's manual, SRCS stated, "I am not aware of that we would need to keep a maintenance log. We've only been cleaning it. I have not read the user's manual." SRCS stated for machine checks, it would be supervisor responsibility to establish daily and end of the month check. SRCS confirmed that the facility does not have a policy for Respiratory Services Department to conduct monthly check on the portable ventilator including having a maintenance log. There was also no log to indicate that there was a daily and monthly check completed for the portable ventilators.

Based on observation, interview, and record review, the facility failed to ensure the respiratory care services ordered (ventilator settings- used to control how much air is delivered into the patient's lungs) were documented in the medical record of one of the 30 sampled patients (Patient 16).

This deficient practice had the potential to result in miscommunication between healthcare providers, which can lead to treatment errors or incorrect ventilator settings, putting the patient at risk of receiving inappropriate or potentially harmful care.

Findings:

During a review of Patient 16's "History and Physical (H&P- the most formal and complete assessment of the patient and the problem)," dated 7/21/2023, the "H&P" indicated that Patient 16 was brought to the emergency department for evaluation of hematemesis (the vomiting of blood). The H&P further indicated that Patient 16 ' s medical history included diabetes (a disease that occurs when your blood sugar is too high) and hypertension (high blood pressure).

During a concurrent interview and record review on 9/20/2023 at 2:40 p.m. with the Manager of the Intensive Care Unit (MICU), Patient 16's respiratory "Flow Sheet" was reviewed. The flow sheet indicated that Patient 16 was intubated (a tube is inserted through a person's mouth or nose and into the airway to keep, to keep the airway open) on 8/2/2023 at 6:40 a.m.

During a concurrent interview and record review on 9/20/23 at 2:50 a.m. with MICU, Patient 16's electronic medical record (a digital version of a patient ' s paper chart) under orders was reviewed. The MICU stated, "There are no orders (for respiratory ventilator setting- used to control how much air is delivered into the patient ' s lungs) documented." MICU confirmed that verbal orders taken in emergency situations should be transcribed into the electronic medical record "fairly quickly, within an hour." MICU stated that the entry of the orders into the medical record should not be backdated. MICU confirmed that the ventilator settings documented by the respiratory therapist from 6:40 a.m. to 4:20 p.m. on 8/2/2023 did not have a correlated physician order documented in Patient 16's medical record.

During a review of the facility's policy and procedure (P&P) titled "Scope of Service or Care," last revised 3/2023, the P&P indicated, "Respiratory Care is a life-supporting, life-enhancing health care profession practiced under qualified medical direction... The objectives of the Respiratory Care Services Department are to... Provide treatment based on physician order and diagnosis."