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Based on document reviews and interviews, it was determined that the Condition of Participation ("CoP") for Governing Body was not met. The Governing Body's failure to provide oversight of the hospital was evidenced by the failure to ensure a safe environment was provided for one (1) of eleven (11) patients reviewed (Patient #5R); to ensure a patient was not restrained unnecessarily for one (1) of five (5) patients reviewed who were restrained (Patient #5R); to ensure only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R); and to ensure a patient was discharged from an inpatient unit to a psychiatric hospital as identified in one (1) of one (1) patient's discharge planning process (Patient #5R) instead of discharging the patient to the hospital's Emergency Department ("ED").

Findings:

The Governing Body has failed to provide oversight of the hospital as evidenced by the following:

1. Condition: §482.13 CoP: Patient Rights also known as A-0115 - Based on record reviews and interviews, it was determined that the Condition of Participation ("CoP") for Patient Rights was not met as evidenced by the hospital's failure to provide a safe environment for one (1) of eleven (11) patients reviewed (Patient #5R); the failure to ensure a patient was not restrained unnecessarily for one (1) of five (5) patients reviewed who were restrained (Patient #5R); and the failure to ensure only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R). It was determined that the hospital's failure to provide a safe environment for an impulsive suicidal patient constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0115 for details.

2. Standard: §482.13(c)(2) Patient Rights also known as A-0144 - Based on record reviews and interview, the hospital failed to ensure a safe environment for one (1) of eleven (11) patients reviewed (Patient #5R). Patient #5R, who was admitted after an intentional overdose, was assessed as a high risk for suicide, and was impulsive, was able to use items obtained in the environment to attempt to harm self on seven (7) occasions while on constant observation - three (3) incidents occurred on the inpatient unit and four (4) incidents and while in the ED. It was determined that the failure to ensure a safe environment constituted an immediate jeopardy situation starting on 3/10/2021. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0144 for details.

3. Standard: §482.13(e) Patient Rights also known as A-0154 - Based on record reviews and interview, the hospital failed to ensure a patient was not restrained unnecessarily and only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R). See A-154 for details.

4. Condition: §482.43 CoP: Discharge Planning also known as A-0799 - Based on record review and interview, the hospital failed to ensure a patient was discharged from an inpatient unit to a psychiatric hospital as identified in one (1) of one (1) patient's discharge planning process (Patient #5R). Instead, the hospital discharged the patient to the Emergency Department ("ED") of the same hospital and the ED Physicians became responsible for the patient's care and a different contracted crisis agency became involved with the patient. See A-0799 for details.

The cumulative effect of these deficient practices resulted in noncompliance with this CoP.

Based on record reviews and interviews, it was determined that the Condition of Participation ("CoP") for Patient Rights was not met as evidenced by the hospital's failure to provide a safe environment for one (1) of eleven (11) patients reviewed (Patient #5R); the failure to ensure a patient was not restrained unnecessarily for one (1) of five (5) patients reviewed who were restrained (Patient #5R); and the failure to ensure only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R). It was determined that the hospital's failure to provide a safe environment for an impulsive suicidal patient constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

1. Standard: §482.13(c)(2) Patient Rights also known as A-0144 - Based on record reviews and interview, the hospital failed to ensure a safe environment for one (1) of eleven (11) patients reviewed (Patient #5R). Patient #5R, who was admitted after an intentional overdose, was assessed as a high risk for suicide, and was impulsive, was able to use items obtained in the environment to attempt to harm self on seven (7) occasions while on constant observation - three (3) incidents occurred on the inpatient unit and four (4) incidents and while in the ED. It was determined that the failure to ensure a safe environment constituted an immediate jeopardy situation starting on 3/10/2021. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0144 for details.

2. Standard: §482.13(e) Use of Restraint and Seclusion also known as A-0154 - Based on record reviews and interview, the hospital failed to ensure a patient was not restrained unnecessarily and only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R). See A-0154 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on record reviews and interview, the hospital failed to ensure a safe environment for one (1) of eleven (11) patients reviewed (Patient #5R). Patient #5R, who was admitted after an intentional overdose, was assessed as a high risk for suicide, and was impulsive, was able to use items obtained in the environment to attempt to harm self on seven (7) occasions while on constant observation - three (3) incidents occurred on the inpatient unit and four (4) incidents and while in the ED. It was determined that the failure to ensure a safe environment constituted an immediate jeopardy situation starting on 3/10/2021. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

Documentation in Patient #5R's medical record indicate he/she was admitted to the hospital after an intentional overdose of a medication.

From 3/4/2021 to 3/18/2021, the patient was admitted to inpatient units of the hospital and was on continuous observation.

On 3/4/2021 and again on 3/8/2021, the patient was assessed for his/her suicide risk. The Columbia Suicide Severity Rating Scale ("C-SSRS") assessments concluded the patient was at a high risk for suicide.

On 3/4/2021, 3/5/2021, 3/6/2021, 3/7/2021, 3/8/2021, and 3/11/2021, a different type of "Suicide Risk Assessment" was conducted. These assessments stated the patient either had intermittent or constant suicidal ideations and at times verbalized a suicide plan of cutting his/her wrists or taking pills and overdosing.

In addition, the patient's medical record stated the patient expressed statements related to harming himself/herself - he/she wanted to be with his/her dad who had died of cancer; he/she wanted to cut himself/herself deep enough to end his/her life; she/she wanted to die and spoke of how he/she would accomplish this; "I wish no one had found me and they had let me die."; that he/she has a second personality who makes him/her cut himself/herself; asked if the window would break if he/she threw a chair at it.

While on an inpatient unit, the hospital, who was aware the patient had a desire to harm self, failed to ensure the physical environment was safe for this patient. This failure was evidenced by the following incidents that occurred on the inpatient unit while the patient was on continuous observation:
- On 3/13/2021, documentation stated the patient broke off the cap of a moisturizing cream and attempted to slash his/her wrists with the sharp edge;
- On 3/17/2021, documentation stated the patient removed a piece of metal from his/her face mask and was using it to cut his/her wrists. During this incident, the patient also removed the metal grate from the heater, attempted to hit a nurse with it, and hit the window with the metal grate several times; and
- On 3/18/2021, documentation stated the patient pulled the call bell holder off the wall and was "trying to hurt [himself/herself]".

On 3/18/2021, documentation stated the patient was discharged from the inpatient unit, via four-point restraints, and was admitted to the ED.

On 3/18/2021, the inpatient discharge documentation, by a Physician, stated the following:
- The patient was "medically stable, but psychiatrically unstable and unsafe";
- The patient needed an "inpatient psychiatric bed"; and
- The patient was "being discharged from the inpatient service to the Safe Room in the ER [Emergency Room] for safety of [himself/herself] and staff as [he/she] is too violent to be kept safe in the medical unit."

From 3/18/2021 through 3/25/2021, the patient was in the ED, on continuous observation. On 3/25/2021, the patient was discharged home.

On 3/19/2021, documentation stated the patient was assessed for his/her risk of suicide by a crisis worker from an outside agency. This C-SSRS assessment concluded the patient was at a high risk for suicide with "continued reports of SI [suicidal ideation] and reports [he/she] has been cutting since [he/she] arrived at CMMC [Central Maine Medical Center]. Medical staff report the client has been able to make use of any plastic of metal [he/she] finds to cut [his/her] arms. [He/She] has reportedly weaponizes items in [his/her] room such as a heater grate which [he/she] used to assault staff, attempt to break a window and harm [himself/herself] ... [He/She] denies any thought SIB [self-injurious behavior] or HI [homicidal ideations] however admits [he/she] is impulsive and often acts on a whim". On 3/19/2021, the crisis worker also documented that the patient "admits to fleeting SI [suicidal ideations] and is extremely impulsive".

While in Safe Room in the ED, the hospital, who was aware the patient had a desire to harm self, failed to ensure the physical environment was safe for this patient. This failure was evidenced by the following incidents that occurred in the ED while the patient was on continuous observation:
- On 3/19/2021, documentation stated, in the morning, the patient was given a comb to brush his/her hair; the patient refused to return the comb to the staff member; security was called; attempts were made to de-escalate the patient; he/she broke the comb and threw half of it and used the other half to cut his/her arm. "Roughly 20 minutes later, [he/she] took a small piece of the comb that was left on the floor and started cutting [his/her] left forearm with it." The hospital failed to ensure that the piece of the comb, which the patient threw and was on the floor, was removed from the room; thus, the hospital created an environment in which the patient had access to an object which she was known to use to hurt himself/herself;
- On 3/19/2021, an ED Registered Nurse ("RN") documented the patient was sitting on the bed relaxing; he/she started for the electrical outlet; he/she got the outlet cover off and tried to cut his/her wrists with it; the Security Officer saw him/her on the video camera and went to see what he/she had; the patient started flailing about kicking security guard several times and trying to protect the outlet cover; the Security Officer was holding him/her down, was trying to get him/her to relax, and give the cover to them; he/she continued flailing and kicking at both the Security Officer and Patient Care Technician holding him/her down; Security pulled Taser out and dry Tased the patient several times; the cover was taken away; and the patient was put in bed and restraints were initiated. The hospital's failed to ensure the electrical outlet cover was securely fastened to the wall and could not be removed by a patient who was on constant observation via a staff member with the patient and observation via video. An unsafe environment existed in the "Safe Room" of the ED because of this failure;
- On 3/20/2021, documentation stated the patient came out of the bathroom with a small piece of plastic and was hurting himself/herself; he/she had multiple abrasions to his/her left anterior neck; refused to give the plastic to hospital staff; continued to scratch himself/herself; the area was bleeding; and the patient was placed in restraints to remove the object. The hospital failed to ensure the environment in the bathroom was safe for this patient who was known to use any object to self-harm; and
- On 3/22/2021 at 11:30 AM documentation stated the patient was "making vague statements about hurting himself/herself and hearing voices"; at 12:08 PM documentation stated the patient "wrapped blanket around [his/her] neck attempting to hang himself/herself]"; the blanket was noted to be ripped and had a knot in it; and the blankets and sheets were then removed from the patient's room. It is noted that a police officer was "moved to the safe room common area to have a more direct line of vision on patient". The hospital failed to ensure the environment was safe as the patient was able to rip the blankets, tie a knot in the blanket, and wrap the blanket around his/her neck while on constant observation.

On 4/20/2021 at 11:30 AM, ED Technician ("Tech") #1 was interviewed and confirmed Patient #5R stated the patient was cutting himself/herself with the electric outlet cover on 3/19/2021.

On 4/20/2021 at 2:15 PM, the Security Officer involved in the Taser incident on 3/19/2021 was interviewed. He indicated the Dispatcher notified him that that Patient #5R was kicking the wall and grabbing something; when entering the room Patient #5R was bleeding from the left arm: the patient cut himself/herself with the electrical wall cover again; a struggle occurred; the patient cut his/her right arm; the patient was swinging the "weapon" toward staff and refusing to drop the electrical wall cover; and he chose to use the Taser and the patient dropped the electrical wall over.

On 4/21/2021 at 8:00 AM, an ED RN was interviewed. He stated Patient #5R kicked an electrical cover off the wall and was attempting to cut his/her arms with it; he/she exhibited suicidal behaviors every 15-30 minutes; and on the day of the Taser incident; he was outside the patient's door as the 1:1 sitter when the Security Officer came quickly by him into the room trying to de-escalate the patient; and the Officer directed the patient to drop the item he/she was attempting to cut himself/herself with.

On 4/21/2021 at 8:30 AM, ED Tech #2 was interviewed. The ED Tech confirmed on 3/19/2021 Patient #5R was given a comb for his/her hair after showering; he/she wouldn't return the comb; the patient broke the comb in half and tried to cut his/her arms with half of the comb; staff were able to remove the comb from the patient; and the patient found some teeth from the comb and tried to scrape and cut his/her arms; and the patient had to be restrained to be the comb teeth away from him/her. In addition, the ED Tech confirmed the patient had an electrical outlet cover and was cutting himself/herself with that and the area was bleeding and he/she had old cuts on his/her arms from other attempts during that day.

On 4/21/2021 at 9:15 AM, Doctor #2 was interviewed. Doctor #2 was one (1) of two (2) Doctors who had assessed the patient after the use of the Taser on 3/19/2021. Doctor #2 stated the patient was showing signs of suicidal behavior.

On 4/21/2021 at 9:30 AM, Doctor #1 was interviewed. Doctor #1 was on duty at the time Taser was used on 3/19/2021 and had assessed the patient on that day. Doctor #1 stated the patient broke the electrical wall cover and cut him/herself; the patient told her earlier that day he/she had heard voices speaking to him/her; and the patient was sedated and restrained on the previous shift for suicidal behaviors.

Based on the above, the hospital failed to provide a safe environment for this patient who had been admitted after an intentional overdose, was assessed as a high risk for suicide, and was impulsive. On the inpatient unit, three (3) incidents occurred that the patient was able to obtain an object in the environment and harm himself/herself while on 1:1 observation. The patient was discharged from the inpatient unit and admitted to the the "Safe Room" in the ER for safety reasons. However, the move from the inpatient unit to the Safe Room in the ED did not provide the patient with a safe environment as there were four (4) incidents that occurred that the patient was able to obtain an object in the environment and harm himself/herself while on 1:1 observation.

The hospital's "Identifying and Protecting Potentially Suicidal Patients" policy and procedure, last reviewed on 11/25/2019, stated a patient who is in the ED and is at a high risk for suicide is to be on 1:1 within arm's reach at all times. The policy and procedure defined within arm's reach as "observer is positioned in close proximity to the patient such that the patient is in direct line of sight and the observer is able to immediately intervene should the patient attempt self-harm". Based on the interview with the ED RN on 4/21/2021 at 8:00 AM he was outside the patient's door as the 1:1 sitter when the Security Officer came quickly by him into the room trying to de-escalate and direct the patient to drop the item he/she was attempting to cut himself/herself with. Based on this, the hospital failed to ensure that procedures related to safety as outlined in their policy for suicidal patients was followed; therefore, an unsafe environment for this patient was created.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.

Based on record reviews and interview, the hospital failed to ensure a patient was not restrained unnecessarily and only health related interventions were used before the use of a restraint for one (1) of five (5) patients reviewed who were restrained (Patient #5R).

Findings:

Documentation in Patient #5R's medical record indicate he/she was admitted to the hospital after an intentional overdose of a medication. Between 3/4/2021 to 3/18/2021, the patient was admitted to inpatient units of the hospital and was on continuous observation. On 3/18/2021, the patient was discharged from the inpatient unit, via four-point restraints, and was admitted to the Emergency Department ("ED"). On 3/18/2021, the inpatient discharge documentation, by a Physician, stated the patient was "being discharged from the inpatient service to the Safe Room in the ER [Emergency Room] for safety of [himself/herself] and staff as [he/she] is too violent to be kept safe in the medical unit." From 3/18/2021 through 3/25/2021, the patient was in the ED, on continuous observation.

a. Documentation on 3/19/2021, in the morning, stated the patient was given a comb to brush his/her hair; the patient refused to return the comb to the staff member; security was called; attempts were made to de-escalate the patient; he/she broke the comb and threw half of it and used the other half to cut his/her arm. The patient was restrained to get the half of the comb he/she had away from him/her. "Roughly 20 minutes later, [he/she] took a small piece of the comb that was left on the floor and started cutting [his/her] left forearm with it." Staff attempted to de-escalate the patient to remove the piece of the comb he/she was cutting himself/herself with but became combative and required to be restrained.

On 4/21/2021 at 8:30 AM, ED Tech #2 was interviewed. The ED Tech confirmed on 3/19/2021 Patient #5R was given a comb for his/her hair after showering; he/she wouldn't return the comb; the patient broke the comb in half and tried to cut his/her arms with half of the comb; staff were able to remove the comb from the patient; and the patient found some teeth from the comb and tried to scrape and cut his/her arms; and the patient had to be restrained to be the comb teeth away from him/her. In addition, the ED Tech confirmed the patient had an electrical outlet cover and was cutting himself/herself with that and the area was bleeding and he/she had old cuts on his/her arms from other attempts during that day.

The hospital staff failed to remove the comb the patient had thrown onto the floor which created an opportunity for the patient to cut himself/herself which resulted in the use of restraints.

b. A "Risk Management Worksheet" provided to surveyors, dated 3/19/2021, indicated the following: Patient #5R was observed via camera to be "fidgeting" with something on the wall in the Safe Room; security went to the room and observed the patient cutting himself/herself with an unknown object; it was noted that the patient had removed the electrical cover from the wall and was using it to cut himself/herself; the patient was advised to drop the "makeshift weapon"; the patient continued to cut himself/herself; the Security Lieutenant believed the patient "was an imminent threat towards the and feared for the safety" of the patient, the two ED Technicians in the room and himself as he did not know if the patient was going to attack them wit the makeshift weapon or continue to self-harm; the patient was advised to drop the weapon or else get tased; a struggle occurred; the patient was again advised to stop resisting and drop the weapon; the patient refused stated he/she just wanted to kill himself/herself; the Security Lieutenant again feared for the staff's safety; a decision was made to use the "drive stun" to resolve the situation using non deadly force but reasonable force and not risking harm to staff; the Taser was unholstered the Taser and again asked the patient to drop the weapon and to stop resisting staff's holds; the patient continued to be combative and ignored request; the Security Lieutenant "drive stunned" the patient; the first time the connection was not good so a second drive stun was performed which stopped the patient from being combative an the patient agreed to drop the weapon; and then the patient was placed in restraints. The report indicated "a Drive Stun or Touch Stun is an alternative way to gain compliance using the Conducted Electrical Weapon without the two projectiles firing from the Taser cartridge and impacting the subject at a high rate of speed, instead a two inch arch of electrical current at the mouth of the Taser is able to temporarily and partially incapacitate the subject within a matter of seconds not causing internal or external harm or injury". The report also indicted that the Security Lieutenant left that there should be discussion about removing everything from the Safe Rooms, like the electrical outlets and the help alarms and that the patient over the last week has proven how little items like these can be used as weapons to harm himself/herself or others.

Documentation in the patient's record, by a Registered Nurse ("RN"), for 3/19/2021 stated the patient was sitting on the bed relaxing; he/she started for the electrical outlet; he/she got the outlet cover off and tried to cut his/her wrists with it; the Security Officer saw him/her on the video camera and went to see what he/she had; the patient started flailing about kicking security guard several times and trying to protect the outlet cover; the Security Officer was holding him/her down, was trying to get him/her to relax, and give the cover to them; he/she continued flailing and kicking at both the Security Officer and Patient Care Technician holding him/her down; Security pulled Taser out and dry Tased the patient several times; the cover was taken away; and the patient was put in bed and restraints were initiated.

The Hospital's "Security Department Policy or Procedure No. 8350.72", revised 7/2017 and last reviewed 5/2019, related to the deployment of the X26 TASER, Electronic Control Device (ECD) (hereafter referred to as TASER) stated "A TASER will not be used on a Patient per CMH [Central Maine Healthcare] Policy. Exception: (Unless by a Police Officer in the performance of their duties)" and "since the TASER will only be used as response to resistance issues, the Security Officer with the TASER will be the final decision maker".

On 4/20/2021 at 11:30 AM, ED Technician ("Tech") #1 was interviewed and confirmed Patient #5R stated the patient was cutting himself/herself with the electric outlet cover on 3/19/2021.

On 4/20/2021 at 2:15 PM, the Security Officer involved in the Taser incident on 3/19/2021 was interviewed. He indicated the Dispatcher notified him that that Patient #5R was kicking the wall and grabbing something; when entering the room Patient #5R was bleeding from the left arm: the patient cut himself/herself with the electrical wall cover again; a struggle occurred; the patient cut his/her right arm; the patient was swinging the "weapon" toward staff and refusing to drop the electrical wall cover; and he chose to use the Taser; he applied the Taser for five seconds, to the patient's thigh, he realized the Taser did not lie completely flat on the patient's thigh, so he reapplied the Taser again for another five seconds to the patient's thigh; and the patient dropped the electrical wall over. He stated the Doctor was not aware of this occurring; there was no order to use the Taser; and he asked the Doctor to assess the area the Taser was used. He stated they (meaning law enforcement) couldn't arrest Patient #5R as he/she was medically and mentally not cleared to arrest. The police provided around the clock protective custody with 1:1 sitter for the duration of his/her stay.

On 4/21/2021 at 8:00 AM, an ED RN was interviewed. He stated Patient #5R kicked an electrical cover off the wall and was attempting to cut his/her arms with it; he/she exhibited suicidal behaviors every 15-30 minutes; and on the day of the Taser incident; he was outside the patient's door as the 1:1 sitter when the Security Officer came quickly by him into the room trying to de-escalate the patient; and the Security Officer directed the patient to drop the item he/she was attempting to cut himself/herself with.

On 4/21/2021 at 9:15 AM, Doctor #2 was interviewed. Doctor #2 was one (1) of two (2) Doctors who had assessed the patient after the use of the Taser on 3/19/2021. Doctor #2 stated the patient was showing signs of suicidal behavior.

On 4/21/2021 at 9:30 AM, Doctor #1 was interviewed. Doctor #1 was on duty at the time Taser was used on 3/19/2021 and had assessed the patient on that day. Doctor #1 stated the patient broke the electrical wall cover and cut him/herself; the patient told her earlier that day he/she had heard voices speaking to him/her; and the patient was sedated and restrained on the previous shift for suicidal behaviors.

It is expected when a patient needs to be restrained to ensure immediate physical safety that health care interventions are used and that health care interventions would be directed by health care personnel. According to the State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, the Centers of Medicare and Medicaid Services "does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention"; a taser is considered a weapon; "the use of a weapon by security is considered law enforcement action, not a health care intervention"; and "if a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement."

Based on the above information, a non-health care personnel made the decision to use a Taser, a non-health care intervention; a Taser was used by hospital security prior to the use of a restraint; and there was no evidence obtained that indicated that any law enforcement action was taken and this situation was handled as criminal activity.

Based on record review and interview, the hospital failed to ensure a patient was discharged from an inpatient unit to a psychiatric hospital as identified in one (1) of one (1) patient's discharge planning process (Patient #5R). Instead, the hospital discharged the patient to the Emergency Department ("ED") of the same hospital and the ED Physicians became responsible for the patient's care and a different contracted crisis agency became involved with the patient.

Findings:

Documentation in Patient #5R's medical record indicate he/she was admitted to the hospital after an intentional overdose of a medication. Between 3/4/2021 to 3/18/2021, the patient was admitted to inpatient units of the hospital and was on continuous observation.

On 3/6/2021, the patient was medically stable and needed a crisis assessment.

On 3/7/2021, the patient was seen by the contracted crisis agency that provides inpatient consults for this hospital. The patient was determined to meet criteria for an inpatient psychiatric admission; the hospital's Physician supported inpatient placement; the crisis agency case worker completed an inpatient psychiatric bed search; and no beds were available throughout the State.

Daily between 3/8/2021 and 3/17/2021, the patient was visited and assessed by a crisis agency case worker; the patient continued to meet criteria for voluntary inpatient admission; the crisis agency case worker completed an inpatient psychiatric bed search; and no beds were available throughout the State.

Documentation in the patient's record indicated that there had been three (3) incidents in which the patient, who was on one to one observation, was able to obtain an item and either cut his/her wrists or was trying to harm self. Please see A-0144 for details.

On 3/18/2021, a decision was made by Administration that the patient would be moved to a Safe Room in the ED.

On 3/18/2021, and inpatient discharge documentation, by a Physician, stated the following:
The patient was "medically stable, but psychiatrically unstable and unsafe";
The patient needed an "inpatient psychiatric bed"; and
The patient was "being discharged from the inpatient service to the Safe Room in the ER [Emergency Room] for safety of [himself/herself] and staff as [he/she] is too violent to be kept safe in the medical unit."

On 3/18/2021, documentation stated the patient was "discharged" from the inpatient unit, via four-point restraints, and was admitted to the ED.

Upon admission to the ED, a new medical record was created.

On 3/18/2021, Doctor #4, who is an ED Physician, documented the patient presented to the ED from the medical floor for safe room while pending inpatient psychiatric placement; hospital Administration was involved; a decision was made to discharge the patient from the medical floor to the ED due to safety concerns; and he was not involved in this decision but would care for the patient as he/she was physically in the ED and was registered as an ED patient.

Documentation indicated the patient was discharged from the inpatient service to the "Safe Room" in the ED for safety reasons. However, the Safe Room in the ED did not provide the safety for the patient as intended as there were four (4) incidents that occurred that the patient was able to obtain an object in the environment and harm himself/herself while on 1:1 observation in the ED. Please see A-0144 for details.

Between 3/18/2021 through 3/25/2021, the patient was in the ED, and was seen by the ED physician on duty.

On 3/19/2021, the patient was assessed by the contracted crisis agency that provides ED consults for this hospital which is a different contracted crisis agency who was involved with the patient when he/she was on an inpatient unit. The patient was followed by this new contracted crisis agency through 3/25/2021 and the contracted crisis agency continued to look for an inpatient bed. The patient's behavior improved and a safety plan was made for the patient to return home on 3/25/2021 with follow up with his/her community Case Manager and medication management team.

On 4/21/2021, at 10:20 AM, Doctor #4, who admitted the patient to the ED on 3/18/2021, was interviewed. He stated he was informed by the charge nurse that this patient was coming to the ED Safe Room from the inpatient unit; he had not involved in the decision-making process to have patient come to the ED; and he treated this patient as an ED admission.

On 4/21/2021 at 11:00 AM, Doctor #5, who was the patient's attending physician for the last two days the patient was on an inpatient unit, was interviewed. He indicated he conducted a traditional discharge for the patient's transition to the ED as directed by Administration and he was not involved in the decision for the patient to go from the inpatient unit to the ED but he understood it was to promote a safer environment for the patient.