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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 RIGHTS, was out of compliance.

A-0144 Standard: The patient has the right to receive care in a safe setting. Based on observations, interviews, record review, and document review, the facility failed to ensure patient care in a safe setting in multiple areas throughout the hospital: direct patient care staff were not trained to respond to a patient emergency; ligature assessment and mitigation as well as items of ligature risk (anything which could be used for the purpose of strangulation, hanging, or patient harm) and other unsafe items (pens, linen hampers) were not identified in 3 of 3 patient care areas; and, one of one patients was not monitored with 1:1 observations as ordered by his provider to ensure his safety (Patient #6).

Based on observations, interviews, record review, and document review, the facility failed to ensure patient care in a safe setting in multiple areas throughout the hospital: direct patient care staff were not trained to respond to a patient emergency; ligature assessment and mitigation as well as items of ligature risk (anything which could be used for the purpose of strangulation, hanging, or patient harm) and other unsafe items (pens, linen hampers) were not identified in 3 of 3 patient care areas; and, one of one patients was not monitored with 1:1 observations as ordered by his provider to ensure his safety (Patient #6).

Findings include:

A. Cardio-pulmonary rescue (CPR) training

REFERENCE

Job description /Evaluation for a Mental Health Worker read, knowledge, skill and ability (include materials and equipment directly used); CPR (cardio-pulmonary rescue)/First Aid Certification required (training for certification is available).

Email communication from the Vice President Human Resources, dated February 21, 2019, read the date the job descriptions were modified for the Mental Health Workers was 21 December 2015.

1. The facility failed to ensure all Mental Health Workers (MHW) were trained in CPR certification.

a. Review of a Critical Incident Report dated 2/2/19 read Patient #9 experienced a choking episode in the cafeteria while eating lunch. A patient tried to perform the Heimlich maneuver (abdominal thrust to clear the throat when choking) and was unsuccessful. Patient #9 tried to dislodge the stuck food by trying to stick a spoon handle down his throat and was unsuccessful. Another patient was able to successfully perform the abdominal thrust and expelled the food out of Patient #9's throat.

The Critical Incident Report was reviewed on 2/2/19 by Quality Assurance Registered Nurse (RN) #2. She wrote the mental health workers (MHWs) involved did not have CPR certification. Follow-up priority was all direct patient care staff would have CPR certification and the process had begun. The process would include MHW Program Coordinator (PC) #1 and Director of Nursing (DON) #3.

b. Executive Vice President (EVP) #5 was interviewed on 2/21/19 at 11:28 a.m. EVP #5 reported the MHW's training files and personnel files had been reviewed after the 2/2/19 choking episode and there was no evidence the MHWs had CPR training. EVP #5 reported CPR was a job requirement and necessary so staff would be prepared to respond to a patient emergency. EVP #5 was not sure when CPR training had stopped.

c. PC #1 was interviewed on 2/21/19 at 8:32 a.m. PC #1 confirmed she supervised the MHWs. She stated she hired new MHWs and provided orientation and oversight of MHW job responsibilities. PC #1 acknowledged she had reviewed the incident report dated 2/2/19 regarding Patient #9's choking episode. She reported the resolution was for all MHWs to receive CPR training.

d. Quality Assurance RN (RN) #2 was interviewed on 2/21/19 at 9:00 a.m. RN #2 confirmed she had reviewed the incident report dated 2/2/19 concerning Patient #9 and the choking episode. RN #2 stated she contacted PC #1 who reported the MHWs had not completed CPR training. RN #2 stated she would ensure all staff who had contact with patients would be CPR trained.

e. However, in an additional interview on 2/21/19 at 11:12 a.m., PC #1 confirmed none of the MHWs currently had CPR training or were currently enrolled in CPR training. Therefore, MHWs had been providing direct patient care without CPR training for 19 calendar days since the choking episode.

f. DON #3 was interviewed on 2/21/19 at 11:39 a.m. DON #3 confirmed the facility required MHWs to have CPR training. DON #3 stated she was unaware the MHWs had not had CPR training. DON #3 reported the facility did not expect a patient to provide rescue care to another patient.

g. MHW #4 was interviewed on 2/21/19 at 11:57 a.m. She confirmed she did not have a current CPR certification. She stated she was supposed to get her CPR training in June or July 2019. MHW #4 stated she was required to have CPR/first aid training and provide her supervisor with a current card. MHW #4 reported she had provided direct patient care the week of 2/19/19.


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B. Ligature Assessment and Mitigation, and Implementation of Patient Safety Measures

POLICIES

The Ligature Risk Mitigation policy read, staff were to be aware of interior spaces in the hospital. The interior spaces were to be as safe as possible and when feasible, ligature risk items would be identified and eliminated. Furthermore, if not feasible, strategies and methods to mitigate the risk should be instituted. Additionally, the policy stated the leadership and clinical staff were to be aware of potential environmental risks.

The Telephone Use, Patient policy read handsets/cords will be disconnected from the base when not in use, and stored in a locked cabinet. Patients will be provided privacy during telephone calls, yet remain within the sight of floor staff to ensure patient safety. Additionally, the policy stated once calls were completed, telephones would be returned to staff for handset/cord storage in a locked cabinet for safety purposes.

The Patient Safety Policy read, short flexible pens provided by hospital staff would be available upon request, and returned to staff when writing was completed.

1. The facility failed to develop and implement a ligature risk assessment and mitigation plan to ensure patient safety.

a. On 12/5/18 at 11:26 a.m., a copy of the facility's ligature risk assessment and mitigation plan was requested from Operations Director (OD) #13. At 11:43 a.m., an interview with OD #13 revealed ligature risk assessments were completed during safety inspections and if something concerning was identified, it would be noted on the safety inspection documentation for follow up with the quality department.

b. On 2/19/19 at 9:00 a.m. the ligature risk assessment and mitigation plan was requested again from OD #13. At 12:57 p.m., OD #13 stated the facility did not have a document which identified ligature risk items or a mitigation plan; rather, the staff was actively monitoring for ligature risks at all times. She stated the new building was built to be ligature free and this issue was discussed extensively prior to construction of the new building.

c. On 2/20/19 at 11:48 a.m., the facility provided a document titled Mitigating Ligature Risk in the Hospital. This document referenced the policy, Ligature Risk Mitigation, but the document did not identify the governing body's approval or a date of implementation.

An interview was conducted with Hospital Medical Director (HMD) #14 on 2/20/19 at 5:38 p.m. HMD #14 confirmed ligature risk assessments were completed on a daily basis during safety rounds. In reference to the document titled Mitigating Ligature Risk in the Hospital, HMD #14 stated it was created in the last couple weeks and it had not been through the governing body's approval process and therefore was not an active policy. Furthermore, he verified there was no ligature risk assessment or mitigation plan for the old building or the new building.

2. The facility failed to identify phone cords as items of ligature risk

a. Observations of the three inpatient units were conducted on 2/18/19 through 2/21/19 and revealed unsecured phone cords, contrary to facility policy.

On 2/18/19 at 2:50 p.m., during the initial facility tour, a telephone with two separate cords was observed outside of the room identified as the quiet room on the 200 unit. Additionally, on 2/18/19 at 3:20 p.m. and 2/19/19 at 9:10 a.m., two more phones with two cords each were observed on the 100 and 300 units.

b. Observations on 2/19/19 revealed unsupervised use of the telephone by patients, contrary to facility policy that patients would remain within staff eyesight while using the telephone.

On 2/19/19 from 7:52 a.m. to 8:18 a.m., observations were conducted on the 100 unit from the care team area. Starting at 7:52 a.m., one patient was observed using the telephone outside of the quiet room. The care team area had no staff members present to monitor the telephone and the cords. At 8:01 a.m., another patient was observed using the telephone outside the quiet room with no staff in the vicinity of the patient or in the care team area. At 8:02 a.m., staff members were observed at the care team station, but remained with their backs to the patient using the telephone. At 8:10 a.m., a staff member was observed returning to the care team area to address another patient at the care team desk; the staff member was noted glancing in the direction of the patient using the phone. However, the patient was observed using the phone with no direct staff supervision for a period of 9 minutes.

c. On 2/19/19 at 9:11 a.m., an interview was conducted with Mental Health Worker (MHW) #6. MHW #6 stated, consistent with facility policy (see above), if someone was using the phone, staff was expected to monitor the patient for safety. Furthermore, MHW #6 explained someone should always be present at the care team area to monitor the phone. MHW #6 confirmed the cords for the phone in the patient care area were probably too long and could easily be taken if not monitored.

In a subsequent interview, however, at 3:53 p.m., MHW #6 stated adolescents were required to remain outside of the quiet room while using the phone, but the adults were allowed to be in the quiet room with the door cracked; these statements conflicted with MHW #6's earlier interview as well as an interview with PC #1 on 2/21/19 at 8:32 a.m. and facility policy.

d. On 2/20/19 at 12:29 p.m., an interview and demonstration was conducted on unit 300 with Security Officer (SO) #7, regarding the phone cords present on all three units. The SO removed the telephone cord from the phone and the wall and placed the cord in a space between the door and the pressure sensor for the ligature alarm on the top of the door that was in place for patient safety. However, when the cord was placed in this space and downward force applied, the pressure sensor for the alarm over the door was not activated. SO #7 confirmed the phone cord did not activate the ligature alarm at the top of the door.

On 2/20/19 at 12:29 p.m., following the above demonstration, an interview was conducted with Registered Nurse (RN) #8 who was sitting at a secondary care team area on the same unit during the demonstration. RN #8 confirmed he was not able to visualize the cord being placed over the door from his location. RN #8 stated this was a concern and he would have hoped a staff member was present at the care team area directly across from the phone for observation.

e. On 2/21/19 at 8:06 a.m., an interview was conducted with Executive Vice President (EVP) #5. EVP #5 stated the phones previously on the units had been replaced with cordless phones as of the previous night. On 2/21/19 at 9:56 a.m., a tour of unit 200 was conducted and verified the phone had been changed to a cordless handset, but the base of the replacement phone continued to have two wound up cords in the patient care area. The facility failed to identify the cords on the new phones as a continued ligature risk to the patients.

3. The facility failed to identify, monitor and track pens provided for patient use.

a. On 2/21/19 at 9:30 a.m., MHWs' competencies from orientation were reviewed. This review revealed a document titled Daily References and Guidelines-Mental Health Worker/Clinician/Security (MHW Guidelines) which read staff was to keep track of bendable pens given to patients and each patient must return the pen when done.

b. On 2/21/19 at 11:13 a.m., an interview was conducted with PC #1. PC #1 stated the facility used a softer, flexible pen for patient safety. She stated the pens were kept at the care team station and patients could ask to use one. She further stated, contrary to facility policy and MHW Guidelines (see above), once provided to the patient, the pens were no longer tracked by staff. PC #1 further explained it was the responsibility of the MHWs to round up the pens if found. PC #1 stated if a patient was not safe to have a pen, he or she would not be provided one.

c. On 2/19/19 at 3:46 p.m., an observation was conducted with Security Officer (SO) #15 during security rounds. During this observation, the security officer identified and collected six pens from patient bedrooms and conference rooms which were in patient care areas. Additionally during this observation, SO #15 identified a patient using a pen in their bedroom with the door closed and instructed the patient to leave the door cracked for safety purposes.

d. On 2/21/19 at 10:03 a.m., an observation was conducted on the 300 unit with Security Officer (SO) #10. A cup full of pens was observed sitting on the counter at the care team station and available for patient use. SO #10 stated the free access to the pens was in contrast to his understanding of facility policy that pens would be distributed upon request and returned to staff after use. SO #10 stated the pens for patient use (shortened, flexible pen) were safer than normal pens but there could still be a risk with them. SO #10 said people could potentially self-harm or harm others with the pens.

4. The facility failed to monitor and remove linen hampers in patient care areas. Two hampers, identified by staff as a safety risk, were observed in patient care areas.

a. On 2/20/19 at 10:40 a.m., an observation of security safety rounds with SO #7 was conducted. SO #7 stated security rounds were conducted three times per shift on every unit and patient care area in order to identify ligature risk items and ensure patient safety within the facility. Upon arrival to the 100 unit, a laundry hamper was identified in the hallway adjacent to patient bedrooms by SO #7. SO #7 removed the hamper from the patient care area and placed it in an area accessible only to staff.

b. On 2/21/19 at 9:30 a.m., a review of MHWs' competencies from orientation was reviewed. The Daily References and Guidelines-Mental Health Worker/Clinician/Security (MHW Guidelines) read laundry hampers should not be left on the unit, except for during ADLs (activities of daily living) when patients may want to discard their towels. Review of the facility ADL schedules revealed the schedule for morning ADLs in adult units (unit 100 and 200) was from 5:30 a.m. to 6:20 a.m. The morning ADL schedule for the adolescent unit (unit 300) was from 6:00 a.m. to 7:00 a.m.

c. On 2/21/19 at 10:00 a.m., a tour was conducted of the 100 unit with SO #10. While on tour a laundry hamper was again identified in the hallway adjacent to patient bedrooms, but was not identified by staff or relocated.

d. On 2/21/19 at 11:13 a.m., an interview was conducted with PC #1. PC #1 stated the laundry hampers on each of the units were to be kept in the staff area, away from patient care areas. She explained the risk with the laundry hampers being left unsupervised in patient care areas was the presence of a drawstring on the bag which a patient could use for self-harm as well as the metal portion of the bin could be light enough to pick up and be used as a weapon.

She further explained the hampers were brought out during ADLs so the patients could place their dirty linens in the hampers; however, after completion of the ADL time (see ADL schedules above), the hamper was to be moved back to the staff area where it was not accessible to patients.



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C. Patient monitoring

POLICY

The Observation Precautions policy read, the purpose was to ensure a safe environment for patients at immediate risk to themselves or others and to establish specific guidelines for staff observation of these patients. Level 1- 1:1 observation: The patient is to be within staff's arm's reach at all times. Constant visual monitoring and programming one patient with one staff member will be maintained day and night unless ordered otherwise. Staff must be within arm's reach during toileting and showering. Patients on this level are considered of highest risk.

1. The facility failed to provide 1:1 observation ordered for one patient's safety while in the bathroom.

a. On 2/19/19 at 7:58 a.m., Patient #6 was observed returning to his room from the bathroom, unsupervised. The MHW assigned to monitor him was sitting in a chair outside his room and on the other side of the hall. According to Patient #6's medical record, he was ordered to have 1:1 observation - within arm's length, on 2/18/19 at 8:00 a.m. due to disorganized and delusional thought process.

During the observation, MHW #9 was interviewed. MHW #9 stated she had been employed at the facility for one month and this was the first time she had been assigned to monitor a patient who was ordered to have 1:1 observation. Additionally, MHW #9 stated she had not received any training regarding how to monitor a patient ordered 1:1 observation. MHW #9 stated she did not know why Patient #6 had been ordered 1:1 observation and she had not received a report on him. MHW #9 explained, contrary to facility policy (see above), that she thought she was supposed to have Patient #9 in her line of sight at all times, except when he went to the bathroom.

On 2/19/19 at 1:19 p.m., a second observation was made of Patient #6 returning to his bedroom from the bathroom, again unsupervised. Patient #6 he stated he showered and went to the bathroom unsupervised on a routine basis.

b. On 2/19/19 at 1:25 p.m., an interview with MHW #4 was conducted. MHW #4 stated all staff were informed of patient precautions and supervision status during shift report which happened at the beginning of the shift. MHW #4 stated a patient ordered 1:1 observation would require staff to be with the patient constantly. MHW #4 stated when she monitored a patient ordered to have 1:1 observation, she would sit in a chair in the doorway. Additionally, contrary to facility policy (see above), MHW #4 stated the supervision a 1:1 patient received while in the bathroom was determined by patient and staff gender. MHW #4 explained since the MHW assigned to monitor Patient #6 was female and the patient was male, he could go to the bathroom alone. She further stated if the patient was female, the female MHW would escort her to the bathroom for safety

c. On 2/19/19 at 1:45 p.m., an interview with Registered Nurse (RN) #11 was conducted. RN #11 stated she was the nurse assigned to Patient #6 today. She stated Patient #6 was ordered to have 1:1 observation because he had disorganized thought processes. RN #11 stated monitoring a person who was ordered 1:1 observation could vary based on why it was ordered and how the provider ordered the monitoring. RN #11 explained, contrary to facility policy (see above), that sometimes staff escorted 1:1 patients to the bathroom, sometimes they went alone, sometimes staff stood outside the door and talked to them.

d. On 2/21/19 at 8:33 a.m., an interview with PC #1 was conducted. PC #1 stated her role was to oversee the MHWs and ensure they were performing their jobs. PC #1 stated she expected all staff to follow policies at all times and staff did not have the discretion to determine if they wanted to follow policies or not. PC #1 stated the facility attempted to schedule the same sex staff to monitor a patient on 1:1 observation. She stated a patient on 1:1 observation should be within arm's length of staff at all times and should be escorted to the bathroom for safety. PC #1 stated there was no specific training during general orientation regarding 1:1 observation of patients. PC #1 stated the facility did not order 1:1 observation frequently, but her expectation was for staff to know how to monitor patients on 1:1 observation and to know why they were ordered 1:1 observation.

Review of the MHW training checklist revealed close observation process was a training category to be signed by the new employee and trainer.

e. On 2/20/19 at 12:59 p.m., the quality assurance nurse (RN #2) was interviewed. RN #2 stated the purpose for policies was to ensure staff provided consistent care. RN #2 stated a person ordered 1:1 observation should never be out of the line of sight of a staff member. RN #2 stated staff did not have discretion whether or not to follow policies. Additionally, RN #2 stated all staff were expected to know the policies and all staff had access to policies to review if they were unsure of facility processes.

f. On 2/21/19 at 8:06 a.m., an interview with the executive vice president (EVP) #5 was conducted. EVP #5 stated staff caring for a patient ordered 1:1 observation was expected to be within arm's reach of the patient to ensure safety. EVP #5 stated staff was expected to escort a patient to the bathroom for safety. EVP #5 stated bathrooms were a location of high risk for self-harm. EVP #5 stated the purpose of policies was to assist staff to understand processes and to provide consistent care. EVP #5 stated staff were not allowed to make exceptions in monitoring a patient unless it was ordered by the physician. Such a change should be recorded in the medical record.