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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient's Rights was out of compliance.

A 0144- §482.13 (c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on observations, document review, and interviews, the facility failed to ensure all patients received care in a safe setting. Specifically, the facility failed to ensure items that were identified by staff as a self-harm risk were not accessible to patients at risk for suicide and aggressive/homicidal behaviors in one of one acute inpatient adolescent psychiatric units observed.

Based on observations, document review, and interviews, the facility failed to ensure all patients received care in a safe setting. Specifically, the facility failed to ensure items that were identified by staff as a self-harm risk were not accessible to patients at risk for suicide and aggressive/homicidal behaviors in one of one acute inpatient adolescent psychiatric units observed.

Findings include:

Facility policies:

The Patient Precautions policy read, suicide precautions and self harm precautions include strict sharps count in the unit and continuously assessing the environment to assure no access to potentially self harm means. Homicide/physical aggression/assault precautions include keeping the milieu free from contraband or potential weapons.

The Control of Contraband policy read, contraband is defined as any substance or item that is potentially dangerous to self or others. Searches and safety rounds are conducted to ensure that no disallowed items are present, with particular attention to patients on special precautions.

1. The facility failed to ensure pencils were not accessible to patients at risk for suicide and aggressive/homicidal behaviors.

A. Observation

i. On 10/10/23 at 4:21 p.m., observations were conducted on the Maple inpatient adolescent acute psychiatric unit. Observations revealed nine adolescent patients being lined up by staff in the hallway adjacent to the common activity area. Further observations revealed nine pencils left behind by patients on tables in the common area. Registered nurse (RN) #1 quickly picked up pencils following the observation of pencils being left on tables while patients lined up in the hallway for supper. Throughout the observation, there was no evidence of a process for a strict sharps count to ensure the number of pencils given out to patients matched the number of pencils left unattended in the common activity area.

B. Document review

i. Orders for special precaution for the nine patients present on the Maple inpatient adolescent acute psychiatric unit on 10/10/23 were reviewed. The document review revealed Patient #1, Patient #2, and Patient #8 were on suicide and aggression/homicide precautions. Further review revealed Patient # 4, Patient #5, Patient #6, Patient #7, and Patient #9 were on suicide precautions. Additionally, Patient #3 was on aggression/homicide precautions.

This was in contrast to the Patient Precautions policy which read, suicide precautions and self-harm precautions included strict sharps count in the unit and continuously assessing the environment to ensure no access to potential self-harm means. Homicide/physical aggression/assault precautions included keeping the milieu free from contraband or potential weapons.

Additionally, this was in contrast to the Control of Contraband policy which read, searches and safety rounds were conducted to ensure that no disallowed items were present, with particular attention to patients on special precautions.

C. Interviews

i. On 10/11/23 at 7:57 a.m., an interview was conducted with mental health specialist (MHS) #2. MHS #2 stated staff considered pencils, sporks (a utensil that combined a fork and spoon), and markers to be sharps. MHS #2 stated staff allowed all patients to have these items unless the patient was on a sharps restriction. MHS #2 stated patients who were on self-harm precautions would require sharps restrictions. MHS#2 stated suicidal or aggressive/homicidal patients did not have sharps restrictions. MHS #2 stated staff tracked sharps through counting the items, however, the manner of tracking sharps varied by staff member. MHS #2 stated some staff members wrote patient names on paper, while others used tally marks on paper, crossing off names or tally marks when patients returned the sharps. Additionally, MHS #2 stated the time of sharps collection was also variable. MHS #2 stated sometimes staff collected pencils at the end of the activity, and sometimes they collected pencils at the end of the shift.

ii. On 10/11/23 at 9:43 a.m., an interview was conducted with MHS #3. MHS #3 stated any patient could have sharps unless the patient was ordered on sharps restrictions. MHS #3 stated she used sticky notes to track patients who had sharps and when patients returned the sharps. MHS #3 stated if a patient was suicidal or aggressive/homicidal, the patient was allowed to have the sharps unless their history included using sharps to attempt suicide or harm someone else. MHS #3 stated it was important to track sharps on the units so staff were aware if patients were collecting sharps to use incorrectly. MHS #3 stated patients who used sharps incorrectly included sharps used for harming themselves or others.

iii. On 10/11/23 at 11:05 a.m., an interview was conducted with RN #4. RN #4 stated staff tracked sharps by keeping a close inventory on the items. RN #4 was uncertain of the exact process. RN #4 stated he assessed patients for self-harm risk prior to giving out sharps. RN #4 stated he asked the mental health specialists to help keep track of patients who had sharps and made a note on the daily report sheet of which patients had sharps. RN #4 stated it was important to track sharps because patients were admitted to the facility because of self-harm, suicidal and homicidal behaviors. RN #4 stated not tracking sharps placed patients at risk of harming themselves or others.

iv. On 10/11/23 at 1:07 p.m., an interview was conducted with director of nursing (DON) #5. DON #5 stated tracking sharps was not a formal process. DON #5 stated the expectation for strict sharp counts was applicable for self-harm patients as well as suicidal and aggressive/homicidal patients. DON #5 explained staff were expected to keep track of sharps when they were handed out to patients and when they were returned at the end of an activity. DON #5 stated tracking sharps was important so patients did not access something that harmed themselves or others.

The observation with RN #1 and interviews conducted with MHS #2, MHS #3, and RN #4 were in contrast to the facility's Patient Precautions policy which read, suicide precautions and self-harm precautions included strict sharps count in the unit and continuously assessing the environment to ensure no access to potential self-harm means. Homicide/physical aggression/assault precautions included keeping the milieu free from contraband or potential weapons.

Additionally, the observation and interviews were in contrast to the control of contraband policies which read, searches and safety rounds were conducted to ensure that no disallowed items were present, with particular attention to patients on special precautions.