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Based on observation, review of medical records, facility documents, and staff interview, it was determined the facility failed to ensure patient rights were protected.

Findings include:

1. The facility failed to ensure that patients' are informed of their rights. (Refer to Tag A 117)

2. The facility failed to ensure that patients' are afforded a timely plan of care to meet their psychological needs. (Refer to Tag A 130)

3. The facility failed to ensure that all patients receive care in a safe setting. (Refer to Tag A 144)

4. The facility failed to ensure facility contraband policies are adhered to. (Refer to Tag A 144)

5. The facility failed to ensure the Comprehensive Treatment Plan is amended after the use of restraints or seclusion, according to facility policy. (Refer to Tag A 166)

6. The facility failed to ensure that a patient in restraints is monitored and reassessed by staff according to facility policy. (Refer to Tag A 175)

Based on staff interview and review of two (2) of two (2) medical records of discharged patients, it was determined the facility failed to ensure that the patient or the patient's representative, receives a copy of the Important Message from Medicare (IM) prior to discharge.

Findings include:

1. Review of Medical Record #5 and Medical Record #7 revealed that patients, upon admission, were not provided with a copy of the IM form.

a. Both medical records lacked evidence that the IM form was provided to the patients.

2. Upon interview on 1/7/20, Staff #64 confirmed that the IM discharge notification form was not provided to patients prior to discharge.

Based on review of eight (8) of eight (8) medical records, review of facility documents, and staff interview, it was determined the facility failed to ensure a timely plan of care by the Social Worker (SW), in order to enable patients to participate in the implementation of their care.

Findings include:

Reference: Facility policy "Progress Notes" states, " ...Progress Notes: 1. SW [Social Worker] documentation MUST be weekly for first 8 weeks of admission and monthly thereafter. Weekly notes must be within 7 days from the previously written progress note. The monthly note has to be every 30 days. ...All sections must be completed-no blanks. ..."

1. Upon medical record review, it was determined that SW documentation was not completed weekly and/or monthly, as it should be, as indicated in the above policy.

a. Review of Medical Record #1, revealed the most recent "Social Services Monthly Progress Note," was dated 11/19/19.

(i) There was no evidence of a December 2019 monthly progress note.

b. Review of Medical Record #2, revealed the most recent "Social Services Monthly Progress Note," was dated 11/20/19.

(i) There was no evidence of a December 2019 monthly progress note.

c. Review of Medical Record #19, revealed the most recent "Social Services Monthly Progress Note," was dated 11/29/19.

(i) There was no evidence of a December 2019 monthly progress note.

d. Review of Medical Record #20, with a date of admission (DOA) of 11/25/19, revealed two (2) weekly progress notes; 12/2/19 and 12/9/19.

(i) There was no evidence in the medical record, of the required weekly progress notes for the weeks of 12/16/19, 12/23/19, 12/30/19, 1/6/20, and 1/13/20.

(ii) The weekly progress notes on 12/2/19 and 12/9/19, contained sections that were not complete.

e. Review of Medical Record #21, with a DOA of 11/13/19, revealed the first weekly progress note in the medical record was dated 11/20/19.

(i) The second progress note in the medical record was dated 11/29/19, which was two (2) days late as per the above facility policy.

(ii) The third progress note in the medical record was dated 12/6/19, which was two (2) days late as per the above facility policy.

(iii) The fourth progress note in the medical record was dated 12/12/19. This was one (1) day late as per the above facility policy.

(iv) There was no evidence of the required weekly progress notes for the weeks of 12/18/19, 12/25/19, 1/1/20, and 1/8/20.

f. Review of Medical Record #22, revealed the most recent "Social Services Monthly Progress Note" was dated, 11/18/19.

(i) There was no evidence of a December 2019 monthly progress note.

(ii) The weekly progress note contained sections that were not complete.

g. Review of Medical Record #23, revealed the most recent "Social Services Monthly Progress Note" was dated 11/19/19.

(i) There was no evidence of a December 2019 monthly progress note.

h. Review of Medical Record #24, revealed the most recent "Social Services Monthly Progress Note" was dated 11/29/19.

(i) There was no evidence of a December 2019 monthly progress note.

2. The above findings were confirmed with Staff #64 on 1/9/20 and 1/14/20.

A. Based on observation and staff interview, it was determined the facility failed to ensure patient rooms are equipped with ligature resistant furniture.

Findings include:

1. On 1/7/20 at 11:50 AM, in the presence of Staff #1, the following ligature risks were identified during a tour of the facility:

a. In Patient Rooms #D101, #D102, #D109 and #A212, were the following:

(i) Two (2) of two (2) wardrobes with full size doors, were equipped with hinges at the tops of the doors, creating a ligature risk.

(ii) Two (2) of two (2) night stands, with pull out drawers, creating a ligature risk.

(iii) Two (2) of two (2) night stands, with holes approximately three (3) inches in diameter on the back side, creating a ligature risk.

b. During interview, Staff #1 confirmed the above findings.

These findings resulted in an Immediate Jeopardy (IJ). The Chief Executive Officer was informed of the IJ and was provided with the IJ Template on 1/7/20 at 3:20 PM.

On 1/9/20 the facility submitted an acceptable removal plan for the IJ findings.

On 1/14/20, an onsite revisit was conducted. A tour of patient rooms was completed to confirm the removal of furniture with potential ligature risks. Staff education of environmental safety checks; including ligature risks of patient furniture, medical bed compliance, and monitoring tools, was reviewed.

It was determined that the components of the removal plan were implemented. As a result of this revisit, the IJ for Tag A0144 was removed as of 1/14/20.

B. Based on observation, review of manufacturer's instructions for use, and staff interview, it was determined the facility failed to ensure patients receive care in a safe setting when using soft suicide prevention doors.

Findings include:

Reference: The "Kennon Soft Suicide Prevention Doors (SSPD)", instructions for use, page 6 states, " ...Never allow the magnetic hinge of the SSPD within 12 inches of a person with a pacemaker or similar medical device. The strong magnetic fields can affect the operation of such devices. ..."

1. On 1/14/20 at 1:30 PM, during a tour in the presence of Staff #1, it was revealed that patient bathroom doors had been replaced with soft suicide prevention doors in Patient Rooms #D101, #D102, #D109 and #A212.

a. Patients entering the bathroom will come within twelve (12) inches of the magnetic hinge.

b. During an interview, Staff #1 confirmed there is no facility policy or procedure in place to ensure an individual with a pacemaker does not come within twelve (12) inches of the magnetic field, as indicated in the above reference.

C. Based on observation, review of facility documents, and staff interview, it was determined the facility failed to ensure facility surveillance equipment is operational.

Findings include:

Reference: Facility policy "Digital Surveillance System" states, " ...I. POLICY ...This system can and will be used in cases of professional misconduct and workplace violence, in which Greystone Park has zero tolerance policy in place. ...III. PROCEDURE ...B. RECORDING TIMES -The digital surveillance system shall be operational and recording on a twenty-four hour per-day, seven day per-week, year-round basis.

1. On 1/3/20, upon review of the facility's patient safety monitoring, it was revealed there were areas in the facility in which cameras are not recording.

a. Staff #4 confirmed the following:

(i) Approximately 53% of the facilities cameras are not recording.

D. Based on review of facility policies, facility documents, and staff interview, it was determined the facility failed to ensure implementation of facility policies for patient admissions or returns from day pass/brief visits.

Findings include:

Reference #1: Facility policy "Contraband" states, " ...IV. PROCEDURE: ...2. ...Routine searches are conducted upon admission and are ongoing (when a patient is of unit). (Please refer to the search procedure for more information) ..."

Reference #2: Facility policy "Patient Search" states, " ...I. PURPOSE: To ensure the prohibited items are not brought onto hospital grounds or are removed if they are found. ...IV. TYPES OF SEARCHES A. Routine Contraband Search - A search of a patient, clothing, possession, or incoming packages, and a visual inspection of the clothed person. ...V. PROCEDURE: ...E. All searches will be conducted in the presence of at least two staff who can give their whole attention to conducting or observing the search. ...VI. TYPES OF SEARCHES A. Routine Contraband Search 1. ...This type of search is utilized when patients are newly admitted, when they return from hospitals or outside facilities or Brief Visit(s) ..."

Reference #3: Facility form titled "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" states, " ...BV [brief visit] RETURN ROUTINE CHECK: In effort to decrease contraband in the hospital, a change in process for patient returns was implemented effective Thursday, 12/15/16. A routine check will be conducted whenever a patient returns to the unit from Day passes, Brief visit and off ground trips. Process: 1. Patient will be checked in by the Admission intake area. 2. Front lobby staff will notify the unit of the patient returns and will request the unit staff to come to intake area to complete routine search with the BV return employee. (Two Staff are needed to complete routine searches process) ...6. Staff shall use a hand held metal detector on the patient to determine if there is concealed metal object. ..."

1. Upon review on 1/13/20, of facility log, "Greystone Park Psychiatric Hospital Brief Visit [BV]/Day Passes and Off Ground Events," in the presence of Staff #23, it was determined there were multiple areas of the log that were not completed, incomplete, or were duplicate entries in the following areas:

a. TIME: patients arrival time back to the facility

b. UNIT: patients assigned to

c. NAME (PT.): of patient

d. NAME (L.S.): signature of lead staff (L.S.)

e. NAME (S.S): signature of second staff (S.S.)

f. ROUTINE CONTRABAND COMPLETED YES/NO: to identify that wand and contraband search were completed

2. Upon review of the last four quarters of the 2019 "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events," the following was revealed:

a. There were a total of 526 patients signed in on the BV log.

b. There was one (1) entry that did not have a time entered,

c. There were four (4) entries that did not include the patient's name.

d. There were fifty one (51) entries that included only the first name of the patient.

e. There were five (5) entries that did not have the L.S. name.

f. There were seventeen (17) entries that did not have the S.S. name.

g. There were two (2) entries that did not have either the L.S. or S.S. name.

h. There were thirty seven (37) entries that did not have the contraband checked (yes or no).

i. There were five (5) entries that had contraband checked as "yes" and "no."

j. There were a total of 124 log entries that were not completed, were incomplete, or were duplicate entries.

3. On 1/13/20, upon interview with Staff #23, he/she confirmed the process for a patient returning from a BV, is for the patient to enter through the "Sally Port Unit" in admissions, for a contraband check.

a. It is also the expectation that the L.S. and S.S. complete the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log.

4. Upon inquiring with Staff #23 on 1/13/20, regarding whom is responsible for the quality assurance and accuracy of the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" logs, Staff #23 stated, "there is no monitoring of the log, unless there is some reason to check."

5. Staff #4 on 1/14/20, confirmed there is no evidence that the BV log was being monitored for patient safety/compliance and that there was no evidence that education was implemented.

E. Based upon review of five (5) of six (6) medical records, review of facility policy, facility documents, and staff interview, it was determined the facility failed to ensure their brief visit (BV) and day passes policy is adhered to.

Findings include:

Reference: Facility policy "Brief Visits & Day Passes" states, " ...PROCEDURES: ...B. Responsibilities: ...3. When a patient returns from Brief Visits, it is important that Treatment Team members interview the patient, and the family, ... to assess the patient's response to the BV [brief visit] and document this information in the progress notes ...5. All patients must be checked for contraband before and after going for day pass or BV. The Patient Search Policy is to be followed if needed. ..."

1. Upon review of Medical Record #1 on 1/7/20, the following was revealed:

a. Patient #1 left the facility on day passes on 11/2/19, 11/9/19, 11/16/19 and 11/23/19.

(i) There was no evidence in the progress notes, that Patient #1 was checked for contraband prior to leaving the unit, on the days noted above.

(ii) There was no evidence in the progress notes, that Patient #1 was checked for contraband upon arrival back to the unit, on 11/9/19.

(iii) Upon return from a day pass on 11/23/19, there was no evidence in the progress notes, that Patient #1 returned to the unit, or of a contraband check.

b. Patient #1 left the facility for BV's on 11/28/19, 12/7/19, 12/14/19, 12/21/19 and 12/24/19.

(i) There was no evidence in the progress notes, that Patient #1 was checked for contraband prior to leaving the facility, on the BV's noted above.

(ii) Upon return from the BV, 11/28/19 through 11/30/19, there was no evidence in the progress notes, that Patient #1 returned to the unit or of a contraband check.

(iii) Upon return from the BV, 12/21/19 through 12/22/19, there was no evidence in the progress notes, that Patient #1 returned to the unit or of a contraband check.

c. There was no evidence of a second staff member signature on the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log, for the contraband search of Patient #1, on 12/22/19 at 7:40 PM.

d. There was no evidence on the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log for the return from Patient #1's BV, 11/24/19 through 12/28/19.

e. The progress notes in Medical Record #1, from 11/2/19 to 12/28/19, lacked evidence by the Treatment Team members, of any interviews with the family, assessing the patient's response to the visits.

(i) The above findings were confirmed by Staff #8 and Staff #64 on 1/9/20.

2. Patient #10 returned from a day pass on 11/15/19 at 8:07 PM, and the following was revealed:

a. The "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log was not completed to indicate the Lead Staff (L.S.), or the Second Staff (S.S.).

b. The "Routine Contraband," YES/NO, was not completed.

c. There was no evidence in the progress notes, that the patient was checked for contraband upon arrival back to the unit, from his/her day pass.

d. The above finding was confirmed by Staff #5, on 1/14/2020, at 11:12 AM.

3. Patient #13 left the facility on BV's on the following dates:

- 11/16/19 through 11/17/19
- 11/23/19 through 11/24/19
- 11/27/19 through 12/1/19
- 12/7/19 through 12/8/19
- 12/14/19 through 12/15/19

a. There was no evidence in the progress notes, that Patient #13 was checked for contraband prior to leaving the unit, for the BV's on 11/16/19, 11/23/19, 11/27/19, 12/7/19 or 12/14/19.

b. There was no evidence in the progress notes, that Patient #13 was checked for contraband upon arrival back to the unit, from the BV's, on 11/17/19 and 12/1/19.

c. The "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log was not completed for a contraband check on 12/1/19.

d. The "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log did not have an entry indicating Patient #13 returned to the unit on 12/8/19.

e. The above findings were confirmed by Staff #5 on 1/14/20 at 1:24 PM.

4. Patient #15 returned from a day pass on 12/24/19 at 8:50 PM.

a. There was no evidence in the progress notes, that Patient #15 was checked for contraband prior to leaving the unit on a day pass.

5. Patient #25 returned from day pass on 9/22/19 at 8:40 PM.

a. The "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log was not completed for the contraband check on 9/22/19.

6. The above findings were confirmed by Staff #5 on 1/14/20.


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F. Based on review of facility documents and staff interviews, it was determined the facility failed to ensure that their policy for sharps/tools and pens/pencils is adhered to.

Findings include:

Reference: Facility policy, "Sharps/Tools/Implements in Rehabilitation Services Programs" states, "... Method: Clinician will ensure that; [sic] ... 4. Whenever sharps/tools or pens/pencils have been used in a program, they are to be counted and locked in cabinets before patients or staff leave the program area (if a patient leaves a program during a session, sharps/tools/pencils must be accounted for before they leave). 5. Log sheets will be maintained indicting date, clinician, and comment by individual responsible for the program when sharps/tool/pens/pencils are present in program area. 6...iii) If the sharp/tool/pen/pencil is not recovered notify the immediate supervisor and give the following info ...Supervisor will: 1. Upon notification initiate/conduct an investigation 2. Follow Hospital Unusual Incident Policy. ..."

1. The "Sharps/Tools/Implements Sign Out Log," and the "Sharps Sign Out Log" for 10/1/19 through 1/13/20, was reviewed with Staff #40 on 1/13/20.

a. The review of the "Sharps/Tools/Implements Sign Out Log," revealed the following:

(i) On 11/27/19 at 9:30 AM, two (2) pens were removed from the cabinet and only one (1) pen was documented as returned.

(ii) On 12/5/19 at 9:50 AM, two (2) scissors were removed from the cabinet and only one (1) scissor was documented as returned.

(iii) On 12/19/19 (without time documented), a total of nine (9) items (clippers, shears, blow dryer, flat iron, and trimmer), without quantities noted for each specific item, were removed from the cabinet, and only eight (8) items were documented as returned.

(iv) On 1/9/20 at 1:30 PM, a utility knife was removed from the cabinet. The log indicated that at 2:40 PM, staff initialed the knife as returned, however, the box indicating the number of items returned, was not completed.

b. The review of the "Sharps Sign Out Log," revealed the following:

(i) On 10/11/19 at 1:15 PM, one (1) needle was removed from the cabinet and two (2) needles were documented as returned.

(ii) On 12/27/19 at 1:23 PM, two (2) red/yellow [scissors] were removed from the cabinet. The log indicated that at 2:36 PM, staff initialed the scissors as returned, however the box indicating the number of scissors returned, was not completed.

2. The above findings were confirmed by Staff #40.

a. Staff #40 stated that he/she was not aware of any missed tools or of any unusual incident reports, as required by the above facility policy.

Based on review of one (1) of five (5) medical records, facility documents, and staff interview, it was determined the facility failed to ensure that upon the discontinuation of restraints and/or seclusion, the patient's treatment plan is updated.

Findings include:

Reference #1: Facility policy "Seclusion and Restraint" states, " ...VI. Procedures: ...D. Release of Patients from seclusion or restraint: ...2) Attending or Covering Psychiatrist or MOD: ...c) Ensures that Treatment Team meets with the patient to conduct a debriefing after all instances of seclusion or restraint, in order to review and sign the Treatment Plan Addendum form that was completed at the time of the incident, ..."

Reference #2: Facility form, "Treatment Plan Addendum Following:" states, "...A. The Psychiatrist with input from the Treatment Team, or Nurse ...is to use this form to amend the Comprehensive Treatment Plan after seclusion or restraint episodes ...This form when completed and signed, will be considered as part of the Treatment Plan until the next regularly scheduled treatment plan update and review meeting. Completed form is to be placed ...in the Treatment Plan section of the chart. ..."

1. On 1/9/20 at 12:09 PM, Medical Record #9 was reviewed with Staff #42 and the following was revealed:

a. On 11/16/19, Patient #9 was placed in seclusion at 9:30 AM.

(i) The seclusion was terminated at 11:30 AM.

b. On 12/15/19, Patient #9 was placed in 2 (two) point soft restraints at 6:30 PM.

(i) The restraints were terminated at 7:25 PM.

c. On 1/9/20 at 12:15 PM, Staff #42 confirmed that the "Treatment Plan Addendum" form is to be completed by staff in all instances of seclusion or restraint.

d. Medical Record #9 failed to contain a completed "Treatment Plan Addendum" form, in either of the above referenced instances of seclusion and restraint.

2. The above findings were confirmed by Staff #42 on 1/9/20 at 12:30 PM.

Based on review of three (3) of five (5) medical records, review of facility documents, and staff interview, it was determined the facility failed to ensure that patients' in restraints are monitored and reassessed by staff.

Findings include:

Reference #1: Facility policy, "Seclusion and Restraint" states "...VI. Procedures: ...D. Release of Patients from seclusion or restraint: ...2) Attending or Covering Psychiatrist or MOD: a) Reassess patient if RN (Registered Nurse) requests for a continuation of seclusion or restraint. ...b) Conducts an assessment of the patient with one (1) hour after restraint or seclusion is discontinued and enters a Progress Note documenting results of the assessment. ..."

Reference #2: Facility document, "Psychiatric Progress Note For One-Hour Seclusion or Restraint" states, "...Reassessment Within One Hour of Termination of Seclusion or Restraint: 11. Patient is no longer in seclusion or restraint, and, I have re-evaluated him/her. ..."

1. On 1/9/20 at 12:09 PM, Medical Record #9 was reviewed with Staff #42 and the following was revealed:

a. On 11/18/19 at 9:25 AM, Patient #9 was placed in seclusion.

(i) The RN indicated in the "Reassessment of patient" section of the "Seclusion/Restraint RN Progress Notes," that the patient was "Threatening self/others/environment and Agitated/Out of Control. An order was written at 10:25 AM, to continue seclusion.

(ii) The "Seclusion/Restraint RN Progress Notes" that indicated seclusion was terminated at 12:00 PM.

(iii) The "Psychiatric Progress Note" indicated that the reassessment of the patient occurred at 2:00 PM. This was more than one hour after the termination of seclusion, as indicated in the facility policy.

b. On 12/15/19 at 6:30 PM, Patient #9 was placed in two (2) point soft restraints.

(i) The "Seclusion/Restraint RN Progress Notes" indicated that seclusion was terminated at 7:25 PM.

(ii) There was no evidence in the medical record, that the patient was reassessed, within one hour of the termination of the restraints, as indicated in the above facility policy.

2. The above findings were confirmed by Staff #42 on 1/9/20 at 12:35 PM.

3. On 1/9/20 Medical Record #11 was reviewed, and the following was revealed:

a. On 12/16/19 at 3:28 PM, Patient #11 was placed in four (4) point restraints for one hour.

(i) At 4:25 PM, restraints were terminated.

(ii) There was no evidence in the medical record, that the patient was reassessed, within one hour of the termination of the restraints, as indicated in the above facility policy.

4. On 1/9/20 Medical Record #12 was reviewed, and the following was revealed:

a. On 1/5/20 at 8:28 PM, Patient #12 was placed in restraints for one hour.

(i) At 9:55 PM, restraints were terminated.

(ii) There was no evidence in the medical record, indicating the patient was reassessed within one hour of the termination of restraints, as indicated in the above facility policy.

5. The above findings were confirmed with Staff #23.

Based on observation, review of facility documents, and staff interview, it was determined the facility failed to ensure patient safety.

1. The facility failed to monitor, analyze and implement actions regarding ligatures and contraband throughout the facility, to ensure patient safety. (Refer to Tag A 309)

A. Based on review of facility documents and staff interview, it was determined the facility failed to ensure an ongoing program for quality improvement, where improvement actions are defined, implemented, and maintained.

Findings include:

Reference #1: Facility policy "Contraband" states, " ...IV. PROCEDURE: ...2. ...Routine searches are conducted upon admission and are ongoing (when a patient is of unit). (Please refer to the search procedure for more information) ..."

Reference #2: Facility policy "Patient Search" states, " ...E. All searches will be conducted in the presence of at least two staff who can give their whole attention to conducting or observing the search. ...VI. TYPES OF SEARCHES A. Routine Contraband Search 1. ...This type of search is utilized when patients are newly admitted, when they return from hospitals or outside facilities or Brief Visit(s) ..."

Reference #3: Facility policy "Brief Visits & Day Passes" states, " ...PROCEDURES: ...B. Responsibilities: ...3. When a patient returns from Brief Visits, it is important that Treatment Team members interview the patient, and the family, ... to assess the patient's response to the BV and document this information in the progress notes ...5. All patients must be checked for contraband before and after going for day pass or BV. The Patient Search Policy is to be followed if needed. ..."

Reference #4: Facility document " Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" states, " ...BV RETURN ROUTINE CHECK: In effort to decrease contraband in the hospital, a change in process for patient returns was implemented effective Thursday, 12/15/16. A routine check will be conducted whenever a patient returns to the unit from Day passes, Brief visit and off ground trips. Process: 1. Patient will be checked in by the Admission intake area. 2. Front lobby staff will notify the unit of the patient returns and will request the unit staff to come to intake area to complete routine search with the BV return employee. (Two Staff are needed to complete routine searches process) ...6. Staff shall use a hand held metal detector on the patient to determine if there is concealed metal object. ..."

1. Upon a tour of patient units D1, A2, E2, and B3, on 1/7/20, the following was observed:

a. Wardrobes with full size doors, were equipped with hinges at the tops of the doors, creating a ligature risk

b. Night stands with three (3) pull out drawers, creating a ligature risk

c. Each night stand had two (2) holes on the back side, creating a ligature risk.

d. Desks located in patient rooms contained an upper shelf, bolted to the top of the desk, creating a ligature risk.

e. Office-style chairs with openings, were in patient rooms, creating a ligature risk.

f. A hospital bed located in patient Room #D109 was equipped with an electrical remote control, connected by a two-foot cord, creating a ligature risk.

g. Plastic hangers, were in all patient wardrobes, creating a ligature risk.

2. Staff #1 confirmed that wardrobes, nightstands, desks, and office-style chairs, were also present on the following units: A1, B1, C1, D1, A2, B2, C2, D2, A3, B3, D3, E3, F3, and G3.

3. Upon request for the environmental safety risks assessment of risks in the patient care environment, the following documents were provided, and revealed the following:

a. Facility document "Risk Assessment - Patient Bedroom Furniture (wardrobe closet, desk and night stand) on June 12, 2017 states, " ...Safety Officer completed a risk assessment on the wardrobe closet, desk and nightstand cabinet located in the patient bedroom in the hospital patient care units. ..."Wardrobe - Possible suffocation if the patient while unattended attempts to hang themselves by pinching a device (e.g.= lanyard, sheet, shirt, pants, pillow case) on the wardrobe closed door ...Possible use of the furniture or furniture material for self injurious behavior or as a weapon during unstable behavioral episodes. Possible obstruction of access if furniture is used to block entry or positioned to create trip hazard for responding staff. ...When unsupervised, and based on the above mentioned concerns, I have considered this a SIGNIFICANT RISK since there is enough evidence that physical harm could easily compromise patient safety ...The assessed concerns with the desk are as follows: Possible suffocation if the patient attempts to hang themselves by looping a device around the bookshelf leg on top of the desks ...The assessed concerns with the nightstands are as follows: Possible suffocation if the patient attempts to hang themselves by looping a device around the open drawer. ..."

b. Facility document "Safety Committee Minutes July 18, 2017" states, " ...I. Announcements ...2. Risk Assessments -Bedroom Furniture- these were completed by [name of staff member]. Wardrobes may be adapted by Engineering for high risk patients along with recommendations from the team if they want the top portion of the desks to be removed. ..."

c. Facility document "Monthly Report -November 2017" by Occupation Safety Consultant states, " ...1. Highlights/Initiatives: ... j. Suicide risk assessments ...Patient risk assessment in bedrooms reviewed with [name of staff member] and team who determined closets did tip ..."

d. Facility document "Suicide Risk Assessment of the Environment 2019" states " ...This assessment of the environment did not include patient living areas/units. ..."

e. Facility document "Office of Quality Management - Utilization Management (Nursing) December 2019 Monitoring Criteria" did not address furniture in patient bedrooms, with the exception of medical equipment cords on electric beds.

4. Staff #1 confirmed that on 1/7/20 at 2:30 PM, there was no evidence that the furniture in the patient bedrooms were assessed for patient safety and/or ligature risks after the "Monthly Report - November 2017," as noted above.

B. Based on review of facility documents and staff interview, it was determined the facility failed to ensure an ongoing evaluation, addressing priorities for improved quality of care and patient safety.

Findings include:

Reference: Facility document "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" states, " ...BV RETURN ROUTINE CHECK: In effort to decrease contraband in the hospital, a change in process for patient returns was implemented effective Thursday, 12/15/16. A routine check will be conducted whenever a patient returns to the unit from Day passes, Brief visit and off ground trips. Process: 1. Patient will be checked in by the Admission intake area. 2. Front lobby staff will notify the unit of the patient returns and will request the unit staff to come to intake area to complete routine search with the BV return employee. (Two Staff are needed to complete routine searches process) ...6. Staff shall use a hand held metal detector on the patient to determine if there is concealed metal object. ..."

1. The facility log, "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events," was reviewed with Staff #23 on 1/13/20.

a. Review of the Brief Visit (BV) log, as noted above, indicated there were multiple areas on the log that were not completed, were incomplete, or were duplicate entries (yes/no for contraband search). The areas identified are as follows:

(i) TIME, patients arrival time back to the facility

(ii) UNIT, patients were assigned to

(iii) NAME (PT.)

(iv) NAME (L.S.), signature of lead staff (L.S.)

(v) NAME (S.S), signature of second staff (S.S.)

(vi) ROUTINE CONTRABAND COMPLETED YES/NO, to identify that the wand and contraband search were completed

b. Upon review of the last quarter of 2019 (September 2019 through December 2019) the following was revealed:

(i) There were a total of five hundred and twenty six (526) patients signed in on the BV log.

(ii) There was one (1) entry that did not have a time entry.

(iii) There were four (4) entries that did not include the patients name.

(iv) There were fifty-one (51) entries that included only the first name of the patient.

(v) There were five (5) entries that did not have the L.S. name.

(vi) There were seventeen (17) entries that did not have the S.S. name.

(vii) There were two (2) entries that did not have either the L.S. or S.S. name.

(viii) There were thirty-seven (37) entries that did not have the contraband checked yes or no.

(ix) There were five (5) entries that had the contraband checked as yes and no.

c. There were a total of 124 log entries that were not completed, were incomplete, or had duplicate entries.

d. Upon interview with Staff #23 on 1/13/20, he/she confirmed the process for a patient returning from a BV, is for the patient to enter through the "Sally Port" admission unit for a contraband check. The "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log must be completed.

e. Staff #23 reviewed entries that were marked as both yes and no for contraband search on the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" log, and stated, "the search was done, maybe they found something."

f. Staff #23 confirmed that the "Greystone Park Psychiatric Hospital Brief Visits/Day Passes and Off Ground Events" logs were not monitored, and stated, "unless there is
some reason to check it."

g. Staff #4 on 1/14/20, confirmed there is no evidence that the BV log was monitored for quality assurance, based on the above findings.

A. Based on medical record review, review of facility documents, and staff interview, it was determined the facility failed to ensure the medical staff carried out its responsibilities of completing timely and legible documentation.

Findings include:

Reference #1: Facility "BYLAWS, RULES AND REGULATIONS of the Medical Staff" states, " ...Article XIII. Rules and Regulations ...Section B Admission, Treatment, and Discharge of Patients ...12. Medical Staff would participate in accurate, timely and legible completion of patient's medical records. ..."

Reference #2: Facility policy "Clinical Records" states, " ...III. PROCEDURE: ...D. The Clinical Record shall be recognized as the primary means of communication among staff for the purposes of treatment or review. Therefore, the information contained within it must be as current and accurate as possible. ...E. Assessments (Admission/Annual): ...5. Social Assessment: b. Annual ..."

Reference #3: Facility policy "Progress Notes" states, " ...PURPOSE: ...Progress Notes make up an essential communication tool for team members ...They are to be written in the patient's record clearly and legibly ...."

1. Review of Medical Record #1 on 1/7/20, revealed the following:

a. Patient #1 was admitted to the facility on 5/1/17. The annual psychiatric assessment for 2019 was performed on 10/4/19, four (4) months late.

2. Review of Medical Record #2 on 1/9/20, revealed the following:

a. Patient #2 was admitted to the facility on 12/24/12. The most recent Annual Interdisciplinary Assessment - Psychosocial Assessment in the chart, was dated 1/24/18.

(i) There was no evidence of a 2019 annual assessment in the medical record.

b. The Progress Notes written by Staff #26, for Patient #2, on 12/30/19 and 12/31/19, were not legible.

(i) Staff #5 and Staff #18 were unable to interpret the Progress Notes upon request.

(ii) Staff #5 requested that Staff #26 rewrite his/her 12/30/19 and 12/31/19 Progress Notes, legibly, and then print them for further review.

3. Review of Medical Record #15 on 1/13/20, revealed the following:

a. Patient #15 was admitted to the facility on 7/5/18. The annual psychiatric assessment for 2019 was performed on 10/11/19, three (3) months late.

4. The above findings were reviewed with Staff #5.

B. Based on review of facility documents and staff interview, it was determined the facility failed to ensure their incident reports are completed as per facility policy.

Findings include:

Reference: Facility policy, "Unusual Incident Reporting And Investigation" states, " ...V. Documentation Requirements For Incident Reporting: ...E. The Physician/MOD must complete the medical information portion of there report before the end of the work shift ...F. The Psychiatrist/MOD must evaluate and complete the psychiatry portion assessing the patient's ability to understand the nature of the incident and his/her action (i.e. functional competency). G. All applicable sections of the incident report must be completed. ..."

1. Review of the "Unusual Incident Report Form" in Medical Record #1, on 1/8/20, for an incident written on 12/31/19, revealed the following:

i) The physicians assessment and exam portion of the incident report was incomplete.

2. Upon interview, Staff #32 on 1/8/20 at 12:16 PM, confirmed that all medical staff were to complete the incident report prior to the end of the work shift.

3. The above findings were confirmed with Staff #32.

Based on review of facility documents and staff interview, it was determined the facility failed to follow their policy regarding unusual incident reporting.

Findings include:

Reference: Facility policy "Unusual Incident Reporting And Investigation" states, " ...V. Documentation Requirements For Incident Reporting: A. The employee first involved/aware of the incident must completely and legibly fill out Section 1 of the Unusual Incident Report Form before the end of the work shift. The completed form should then be given to the nurse -in charge/responsible supervisor for further completion of the report. B. The nurse in charge/responsible supervisor must completely and legibly fill out Section 2 of the report and any blanks in Section 1 of the Unusual Incident Report Form before the end of the work shift. C. The Nursing Supervisor/ADON then completes Section 4 of the Unusual Incident Report Form and ensures that other areas of the report are not left incomplete or illegible. ..."

1. Review on 1/8/20, of the "Unusual Incident Report Form" in Medical Record #1, for an incident written on 12/31/19, revealed the following:

a. The general incident information, charge nurse or immediate supervisor review, and nursing supervisor/assistant director of nursing (ADON) initial review portions, of the incident report, were incomplete, as per the above policy.

2. Review on 1/8/20, of the "Unusual Incident Report Form" in Medical Record #2, for an incident written on 12/30/19, revealed the following:

a. The general incident information, charge nurse or immediate supervisor review, and nursing supervisor/ADON initial review portions, of the incident report, were incomplete, as per the above policy.

3. The above findings were confirmed with Staff #32 on 1/8/20 at 11:26 AM.

Based on observation and staff interview, it was determined the facility failed to provide a safe setting that is appropriate for the special needs of the patient population.

Findings include:

1. The facility failed to ensure the overall hospital environment is maintained for the safety and well being of the patients, staff and visitors. (Refer to Tag A 701)

Based on observation and staff interview, it was determined the facility failed to ensure patient rooms are assessed for ligature risks in order to safeguard all patients from potential harm.

Findings include:

1. On 1/7/20 at 11:50 AM in the presence of Staff #1, the following ligature risks were identified during a tour of the facility:

a. In each of the following Patient Rooms #D101, #D102, #D109 and #A212:

(i) Two (2) of two (2) wardrobes with full size doors, were equipped with hinges at the tops of the doors, creating a ligature risk.

(ii) Two (2) of two (2) night stands, with pull out drawers, creating a ligature risk.

(iii) Two (2) of two (2) night stands, with holes approximately three (3) inches in diameter on the back side, creating a ligature risk.

2. Upon interview, Staff #1 confirmed that the above findings were not identified on the facility's environmental risk assessment.

3. The above findings were confirmed with Staff #1.

These findings resulted in an Immediate Jeopardy (IJ). The Chief Executive Officer was informed of the IJ and was provided with the IJ Template on 1/7/20 at 3:20 PM.

On 1/9/20, the facility submitted an acceptable removal plan for the IJ findings.

On 1/14/20, an onsite revisit was conducted. A tour of patient rooms for removal of furniture with potential ligature risks. Staff education of environmental safety checks, including ligature risks of patient furniture, medical bed compliance, and monitoring tools, was reviewed.

It was determined that the components of the removal plan were implemented. As a result of this revisit, the IJ for Tag A0701 was removed as of 1/14/20.

Based on review of facility documents and staff interview, it was determined the facility failed to ensure that the "wands" used for metal detection of contraband, are inspected, tested and/or maintained to ensure safety and quality of patients, staff and visitors.

Findings include:

1. Upon review of the Garrett Super Scanner Metal Detector instruction manual, there was no evidence of manufacturer recommendations for maintenance.

2. Upon interview with Staff #1 and Staff #5 on 1/14/20, at 2:26 PM, it was confirmed the facility does not monitor the wands for safety and quality, and there is no routine scheduled maintenance.