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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that patient rights were protected. This placed current and future patients admitted to the Hospital's 8 East Adult Psychiatric Unit at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting, due to the presence of ligature risks on the 8 East Adult Psychiatric Unit. See deficiency cited at A-144.

The immediate jeopardy (IJ) was identified at 42 CFR 482.13, Patient Rights, on 8/25/2020, due the presence of ligature risks without initiation of sufficient interventions, to ensure patients were free from ligature risks that could potentially cause self harm/injury.

The IJ was announced on 8/26/2020 at 1:15 PM, during a meeting with the Chief Executive Officer; Accreditation and Regulatory Specialists; Chief Nursing Officer; Chief Quality Officer; Chief Medical Officer; Director Environment of Care; Interim Director of Accreditation and Clinical Compliance; Associate Chief Nursing Officer, Psychiatry; Associate Chief Nursing Officer, Emergency Department; Patient Care Director, 8 East Adult Psychiatric Unit; Clinical Nurse Consultant; and Director of Nursing, Quality, and Compliance. The IJ was not removed by the survey exit date of 8/26/2020.

Based on observation, document review, and interview, it was determined that the Hospital failed to ensure care in a safe setting, due to the presence of ligature risks on the 8 East Adult Psychiatric Unit. This has the potential to affect the safety of the 26 patients on census on the 8 East Adult Psychiatric Unit, as of 8/25/2020, and any future psychiatric patients who may become suicidal.

Findings include:

1. On 08/25/2020 between 10:30 AM and 11:30 AM, an observational tour of the Adult Psychiatric Unit was conducted. The following were observed:

- There was a total of 21 patient rooms with medical beds that had side rails, which could be used as anchor points for ligature.
- There were two patients (Pt. #3 and Pt. #4) on suicidal precautions who were assigned to rooms that had these beds with siderails. Pt. #3 and Pt. #4 were not being continuously monitored.

2. On 8/25/2020, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on 8/2/2020 with a diagnosis of schizophrenia. The clinical record indicated that Pt. #3 had suicidal ideation. The History and Physical, dated 8/3/20, included, "...Suicidal Risks Factors... Plan: to hang self...history of multiple suicide attempts..."

3. On 8/25/2020, the clinical record of Pt. #4 was reviewed. Pt. #4 was admitted on 8/24/2020 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #4 had suicidal ideation. The History and Physical, dated 8/24/20 included, "...Suicide Risk Factors...Plan: Jump in front of a train/ off bridge into traffic..."

4. On 8/25/2020, the Hospital's policy titled, "Patient Rights and Responsibilities" (approved 5/21/19) was reviewed and included, "... As our patient, you have the right to... Receive care in an environment that is... safe..."

5. On 8/25/2020, the Hospital's "Risk Assessment" for the 8 East Adult Psychiatric Unit indicated availability of medical beds (beds with side rails) in patients' rooms that were identified as ligature risks.

6. On 8/26/2020, the CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo 18-06 - Hospitals, (dated 12/8/17) was reviewed and included, "...Memorandum Summary... A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation... Background... This is particularly an issue for a patient with suicidal ideation... Psychiatric patients receiving care and treatment in a hospital setting are particularly vulnerable. The presence of ligature risks in the psychiatric patient's physical environment compromise their right to receive care in a safe setting..."

7. On 8/26/20 at approximately 4:00 PM, the Hospital presented a document that included the mitigation plan developed due to the usage of the Spirit Select Mental Health Beds (identified ligature risks). The plan included in addition to the 15 minutes safety rounds, ...1:1 monitoring where applicable and deemed appropriate for care...camera capability is available in the (patient's) room.

8. During the observational tour on 8/25/2020 between 10:30 AM and 11:30 AM, it was noted that Pt. #3 and Pt. #4 were not on 1:1 monitoring, nor was their camera capability available for their assigned rooms.

9. On 8/26/2020, the 9th edition of the "Behavioral Health Guide Design Guide" (dated November 2019) was reviewed and included, " ...ii. Beds: Electrical beds- If electrical operable beds are needed for patients with co-exiting medical issues ...beds that are specifically marketed for use on the behavioral health unit (Spirit Select mental health bed) should be used rather than standard electrically adjustable hospital beds ...However, they do have a significant ligature attachment point risks with the guard rails, headboard, foot board..."

10. On 8/25/2020 between 1:30 PM and 2:00 PM, interviews were conducted with E #3 (Director of Psychiatry, 8 East) and E #4 (Associate Chief Nurse, Psychiatry). E #3 and E#4 stated that the beds with side rails can be used as ligature anchor points for suicidal patients.

11. On 8/26/20 at approximately 1:15 PM, E #3 stated that Pt. #3 and Pt. #4 were on suicidal precautions, and that the room's assigned to these patients did not have cameras, nor were they assigned 1:1 monitoring.