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This CONDITION is not met as evidenced by:

Based on medical record review, document review, policy review, and interview, the facility failed to protect and promote the rights of all patients related to providing care in a safe setting for Patient #1 and Patient #2 (A-0144).

On 03/21/24 at 02:45 PM, an Immediate Jeopardy situation was identified for the CoP of Patient's Rights. At 06:13 PM, the facility implemented immediate interventions that included: re-education of all emergency department clinical staff (Registered Nurses, Licensed Practical Nurses, Patient Care Technicians, Nursing Assistants, Physicians, Physician Assistants, Nurse Practitioners) and security staff on the "Elopement" policy, "Psychiatric Evaluation of Patients in the Emergency Department" policy, and the "Assessing Patient Risk for Suicide" policy. All security staff demonstrated competency in the use of the handheld metal detectors including daily checks and maintenance. Auditing will be conducted daily for a period of 45 days to ensure staff compliance to policy and regulations by the quality assurance department. On 03/22/24 at 09:50 AM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews.

Cross Reference:

482/13(c)(2): The patient has the right to receive care in a safe setting.

Based on policy review, medical record review, document review, and interview, the facility failed to provide care to Patient #1 and Patient #2 in a safe setting.
1.Staff failed to assess Patient #1's suicide risk and implement appropriate precautions prior to allowing Patient #1 to use the bathroom without supervision. Patient #1 was found in the bathroom cutting their left arm with a razor blade.
2.Staff assessed Patient #2 at high risk for suicide with a plan. However, nursing staff did not conduct a SAFE-T assessment and did not implement any safety precautions including observation status. Patient #2 was allowed to use the bathroom, walked past the bathroom, and left the emergency department. Staff did not attempt to stop and/or locate Patient #2 after the elopement.
3.Security staff were not properly trained to use the handheld metal detectors for screening behavioral health patients. Staff were not performing daily checks and/or preventative maintenance.

Findings #1:

Review of the policy "Assessing Patient Risk for Suicide, "last updated 11/29/23, indicated that patients who are being evaluated or treated for behavioral health conditions as their primary reason of care, will be screened for suicidal ideation using the Columbia Suicide Severity Rating Scale. If a patient screens positive for suicide after completion of a Columbia Suicide Severity Rating Scale, suicide precautions will be implemented, and a SAFE-T suicide risk assessment form will be completed by trained staff (registered nurse, social worker, discharge planner, crisis staff, consultation, and liaison staff, etcetera) to determine the suicide risk level of the patient (high, moderate, low). Interventions will be determined by the identified suicide risk level (high, moderate, or low). For high-risk emergency department patients, constant observation (staff continuously observes, always keeping the patient in sight, with hands visible) or special constant observation (staff continuously observes the patient within arm ' s reach, with hands visible) will be ordered as determined by assessment and patient need. A psychiatric care attendant will be assigned. Constant observation should be documented every hour using the constant observation flowsheet.

Review of the policy "Psychiatric Evaluation of Patients in the Emergency Department," last updated 03/08/24, indicated that a person in need of an evaluation may come to the emergency department voluntarily, with family/friends, by police on a 9.41 (Emergency assessment for immediate observation, care, and treatment; powers of certain peace officers and police), on a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order), by agency representatives, or be identified and referred by an emergency department physician. Emergency department staff will escort the patient to an area, assist the patient in changing into a hospital gown, and secure the patient's personal belongings in a locker. The emergency department counselor will assess the patient upon arrival with emergency department staff to determine the level of security required to manage the patient (for example, the appropriate room to place patient). Staff will interview the patient and complete the evaluation. Appropriate measures shall be taken to provide a safe environment. Management of the patient in the emergency department includes, but is not limited to, patient monitoring by nursing staff or security personnel, nursing assessment of physical needs, monitoring of physical condition, maintaining safety, and the use crisis management skills.

Review on 03/21/24 of electronic medical record "Columbia Suicide Severity Rating Scale (CSSR-S)," patient assessment section revealed a patient's suicide risk is assessed by asking a series of simple "yes" or "no" questions: does the patient wish they were dead; does the patient have any thoughts of killing themselves; if so, how would they kill themselves; if the patient has ever had thoughts to kill themselves with intention of acting on thoughts; if the patient had ever started working out the details of how to kill themselves; has the patient had ever done any preparation to end their life. Patients are then scored as high, moderate, or low risk for suicide based on their answer to the questions.

Review on 03/21/24 of electronic medical record "SAFE-T Suicide Risk Assessment," patient assessment section revealed patients are assessed by a clinician. The assessment includes, but not limited to, assessing the patient for suicide and homicide risk factors (suicidal/homicidal ideation, suicide planning, current psychiatric symptoms), asking the patient if they have access to firearms and/or weapons, and assessing internal/external protective factors (patient is able to cope with stress, has family support/therapeutic relationships, positive coping skills). A risk level is assigned, and interventions are selected based on the patient's risk level.

Review on 03/20/24 of the emergency department log dated 03/11/24 revealed Patient #1 presented at 10:53 AM with a chief complaint of a "9.41" mental health evaluation (an order by the director of the community or the director's designee, to direct peace officers to transport a person who appears mentally ill and is conducting themselves in a manner that is likely to result in serious harm to themselves or others, to a hospital designated by the Commissioner as being capable of retaining and treating individuals, for an emergency assessment for immediate observation, care, and treatment for a psychiatric evaluation).

Review of emergency department medical record for Patient #1 dated 03/11/24 revealed the following:
-At 11:15 AM, Staff (K), Physician, performed a medical screening examination after Patient #1 was found cutting their arm with a razor blade, which was able to be wrestled out of their arms by security. Patient #1 snuck a razor blade in past security in their underwear. When Patient #1 got in the restroom, they used the razor blades to inflict multiple lacerations to their left extremity (arm). Patient #1 has done this in the past many times, sneaking in foreign bodies, and then lacerating themself in this facility. Patient #1 is quite agitated now despite multiple medications.
-At 11:19 AM, the registered nurse triage assessment revealed no evidence that a Columbia Suicide Severity Rating Scale was completed at triage.
-At 11:24 AM, Staff (E), Nurse Manager, documented that Patient #1 was checked on in the bathroom and was found to have cut their left arm. Patient #1 did this with razor blades that they left in their underwear that were not found upon being wanded by security. Patient #1 had several large lacerations to their left arm with no atrial bleeding noted. The provider was at the bed side and dressed the area with gauze and wrapping. Bleeding was controlled at this time. The provider will follow up with repairs shortly. Constant monitoring will continue. The provider ordered an x-ray to make sure Patient #1 did not have any more objects hidden.
-At 01:40 PM, Staff (S), Behavioral Health Counselor documented that the SAFE-T Risk Assessment was completed and identified Patient #1 at high risk for suicide with a plan to slice their throat. Patient #1 was a danger to self and needed in-patient treatment. Patient #1 was a high lethality risk at this time due to continued attempts to harm self while in the hospital. High risk suicide prevention and interventions were implemented and include placing Patient #1 on special constant observation, assessment of the psychical environment, and the assessment/removal of contraband.
-At 02:49 PM, the provider ordered special constant observation.
-At 02:50 PM, Staff (K), Physician, documented that Patient #1 was re-evaluated. Patient #1 continued to refuse repair their left arm lacerations. A psychiatric consult was performed to evaluate the patient and agreed with the admission of Patient #1 to the in-patient behavioral health floor. Patient #1 was bandaged and dressed appropriately for their wounds which were no longer bleeding. Patient #1 will be admitted to psychiatric unit for further management and evaluation.
-At 09:45 PM, Patient #1 departed the emergency department for the in-patient behavioral health unit.

Review on 03/21/24 of the document "Security Daily Event Log," indicated that on 03/11/24 at 10:41 AM, Patient #1's personal property was collected by Staff (N), Security Officer. At 10:50 AM, Staff (F), Security Officer, was present with a female Jamestown police office, and Staff (G), Patient Care Technician, while Patient #1 was changed into a safety gown. Staff (F) scanned Patient #1 with the handheld metal detector. Two small bottles of rum were found in Patient #1's personal belongings which were placed in a contraband bag and secured. At about 11:09 AM, Staff (F), Security Officer, discovered Patient #1 in the bathroom cutting their right arm with a razor blade.

Interview on 03/20/24 at 02:00 PM with Staff (E), Nurse Manager, revealed that Patient #1 was brought in by police from an outpatient mental health office for threatening to cut self with a razor blade. When Patient #1 arrived at the emergency department via Jamestown police, they were immediately taken to room #126. The Jamestown police officer stated that they thought all the razor blades were removed from Patient #1 but were not sure. The Jamestown police officer remained presented until Patient #1 was changed and wanded. Staff (E) told Staff (G), Patient Care Technician, to keep an eye on Patient #1. Security helped get Patient #1 changed, to remove belongings, and to "wand" Patient #2 twice. Staff (E) was notified there was an issue with Patient #1 and entered the bathroom with Staff (K), Physician. Patient #1 was found sitting on the bathroom floor with three self-inflected lacerations on their left forearm that were minimally bleeding. Patient #1 had razor blades in a plastic case in their underwear. The lacerations were bandaged. Patient #1 was placed on a strict 1:1 observation (special constant observation) within arm's reach of staff. All three lacerations were sutured by Staff (K), Physician. At the time of the incident, Patient #1 had not been triaged. Staff (E) felt that Patient #1 was calm with police presence and denied wanting to harm self.

Interview on 03/20/24 at 02:19 PM with Staff (F), Security Officer, revealed that Patient #1 was brought in by Jamestown police. Staff (F), Security Officer, assisted with bringing Patient #1 back to room #126. Staff (F) assisted Jamestown police and Staff (G), Patient Care Technician, with changing Patient #1 into a gown. Once Patient #1 was changed, Staff (F) scanned Patient #1 with the handheld (wand) metal detector. Patient #1 was permitted to keep their underwear on while scanned. The wand did not go off when Patient #1 was scanned, indicating that Patient #1 did not have any metal objects on them that could be detected. Patient #1 asked to go to the bathroom and was told yes by Staff (G), Patient Care Technician. Patient #1 went into the bathroom alone. A few minutes later, Staff (G), Patient Care Technician, and Staff (F) opened the bathroom door and saw Patient #1 on the ground bleeding. Staff (F) asked Patient #1 to give them the razor blade. Patient #1 refused and attempted to put the razor blade to their neck. Staff (N), Security Officer, responded and was able to grab ahold of Patient #1's arm to prevent Patient #1 from harming themselves. Staff (F) was able to remove the razor blade for Patient #1's hand and give it to the clinical staff. Staff (F) is unsure of where Patient #1 had the razor blades. There were more razor blades in a plastic case on the sink.

Interview on 03/20/24 at 02:55 PM with Staff (K), Physician, revealed that Patient #1 stated that the razor blades were in their underwear in a plastic package. Staff (K) did not see Patient #1 prior to the incident.

Interview on 03/21/24 at 10:15 AM with Staff (M), Registered Nurse, revealed that Patient #1 had already cut self in the bathroom before they assumed care of the patient. Staff (M) assisted with bandaging Patient #1's arm. Triage was not completed until after Patient #1 cut their arm with the razor blade. Patient #1 was put on a 1:1 observation after the incident and an x-ray was obtained to ensure Patient #1 did not have anything else harmful internally.

Interview on 03/21/24 at 10:19 AM with Staff (C), Director of Emergency Department and Staff (E), Registered Nurse, revealed that Patient #1 was alone in the bathroom. The incident occurred before Patient #1 was triaged and/or a suicide screen was completed. Staff (C) stated Patient #1 should have had a suicide screen done before being allowed to go into bathroom alone. Staff (E) confirmed that the police said they were not sure if Patient #1 had more razor blades on them.

Interview on 03/21/24 at 10:28 AM with Staff (G), Patient Care Technician, revealed that Patient #1 came in with the police and was placed in room #126. Staff (E), Nurse Manager told Staff (G) of Patient #1' s history of hiding razor blades and to keep a close eye on them. The Jamestown police officer and a security officer were in the room when Patient #1 was changed into a gown. After Patient #1 was changed, Staff (G) exited the room, leaving Patient #1 alone in the room. Staff (G) went back to the nursing station. Staff (G) was monitoring Patient #1 via the video monitor and saw Patient #1 enter the bathroom. After a few minutes Staff (G) got concerned and asked Staff (F), Security Officer to accompany them to the bathroom to check on Patient #1. Patient #1 was found on the bathroom floor covered in blood with a razor blade in their hand, cutting themselves. Patient #1 never spoke. Staff (G) then screamed for help. Patient #1 was not on 1:1 observation at the time of the incident. Staff (G) did not receive any direction from the charge nurse until after the incident occurred. Staff (G) stated if a patient is a high risk for suicide, frequent patient checks would be completed and documented every hour/as needed.

Interview on 03/22/24 at 09:45 AM with Staff (N), Security Officer, revealed that Patient #1 was brought to the behavioral health area of the emergency room. Staff (N) assisted with changing Patient #1 into a hospital gown by female staff members. Staff (N) assisted with gathering Patient #1 ' s belongings and inventoried them. During the time of the incident, Staff (N) was in the security office located across from the behavioral health rooms and heard the call that assistance was needed. Staff (N) entered the bathroom of room #126 and found Patient #1 sitting on the floor with Staff (F), Security Officer, and Staff (G), Patient Care Technician. Staff (G), Patient Care Technician, ran to get additional clinical staff. Staff (F), Security Officer, stayed with Patient #1. Patient #1 had a razor blade in their right hand. Staff (N) grabbed Patient #1 arm to prevent Patient #1 from cutting their neck while Staff (F), Security Officer, grabbed the razor blade from Patient #1 ' s hand and gave it to clinical staff. Patient #1 attempted to grab a white plastic sleeve located on the sink that had multiple razor blades in it. Staff (N) was able to grab the plastic sleeve before Patient #1 got to it. The white plastic sleeve was two inches long, one inch wide, and a half inch in depth. When a patient arrives with contraband, the security officer would seize the contraband, and lock it up.

Findings #2:

Review of the policy "Assessing Patient Risk for Suicide, "last updated 11/29/23, indicated that patients who are being evaluated or treated for behavioral health conditions as their primary reason of care, will be screened for suicidal ideation using the Columbia Suicide Severity Rating Scale. If a patient screens positive for suicide after completion of a Columbia Suicide Severity Rating Scale, suicide precautions will be implemented, and a SAFE-T suicide risk assessment form will be completed by trained staff (registered nurse, social worker, discharge planner, crisis staff, consultation, and liaison staff, etcetera) to determine the suicide risk level of the patient (high, moderate, low). Interventions will be determined by the identified suicide risk level (high, moderate, or low). For high-risk emergency department patients, constant observation (staff continuously observes, always keeping the patient in sight, with hands visible) or special constant observation (staff continuously observes the patient within arm ' s reach, with hands visible) will be ordered as determined by assessment and patient need. A psychiatric care attendant will be assigned. Constant observation should be documented every hour using the constant observation flowsheet.

Review of the policy "Psychiatric Evaluation of Patients in the Emergency Department," last updated 12/07/20, indicated that a person in need of an evaluation may come to the emergency department voluntarily, with family/friends, by police on a 9.41 (Emergency assessment for immediate observation, care, and treatment; powers of certain peace officers and police), on a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order), by agency representatives, or be identified and referred by an emergency department physician. Emergency department staff will escort the patient to an area, assist the patient in changing into a hospital gown, and secure the patient's personal belongings in a locker. The emergency department counselor will assess the patient upon arrival with emergency department staff to determine the level of security required to manage the patient (for example, the appropriate room to place patient). Staff will interview the patient and complete the evaluation. Appropriate measures shall be taken to provide a safe environment. Management of the patient in the emergency department includes, but is not limited to, patient monitoring by nursing staff or security personnel, assessment of physical needs, monitoring of physical condition, maintaining safety, and the use crisis management skills.

Review of electronic medical record "SAFE-T Suicide Risk Assessment," patient assessment revealed patients are assessed by a clinician. The assessment includes, but not limited to, assessing the patient for suicide and homicide risk factors (suicidal/homicidal ideation, suicide planning, current psychiatric symptoms), asking the patient if they have access to firearms and/or weapons, and assessing internal/external protective factors (patient is able to cope with stress, has family support/therapeutic relationships, positive coping skills). A risk level is assigned, and interventions are selected based on the patient's risk level.

Review of the policy "Elopement" last updated 12/2020 revealed that if a patient elopes, staff will follow specific interventions. If a patient is a danger to self and/or others, a psychiatry provider may request a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order) to be issued to have the police transport the patient to an emergency department for evaluation to assess the continued need for hospitalization.

Review on 03/21/24 of the emergency department medical record for Patient #2 dated 03/03/24 revealed the following:
-At 12:19 AM, Patient #2 arrived ambulatory at the emergency department by private vehicle for a mental health evaluation.
-At 12:28 AM, an order was placed for an initial SAFE-T suicide risk assessment.
-At 12:32 AM, the triage assessment revealed that Patient #2 was addicted to heroin and their depression had increased approaching the anniversary date of their daughter ' s death on March 15th. Patient #2 stated that they no longer wanted to live. Patient #2 was screened as high risk for suicide according to the Columbia Suicide Severity Rating Scale (scale used to measure patients suicide risk). Patient #2 had a history of suicide attempts by hanging and slitting their own throat. Patient #2 was crying and indicated that they were "not good."
-At 01:24 AM, Staff (T), Registered Nurse documented that Patient #2 asked to use the bathroom. Patient #2 walked by the bathroom and left the facility. The emergency department charge nurse was notified.
-At 01:29 AM, Patient #2 was discharged from the facility as an elopement.
(There was no documentation in the medical record to indicate that a SAFE-T suicide risk assessment was completed, that constant observation or special constant observation status was ordered/implemented, that belongings were checked and contraband was removed/secured, or that measures were taken to find Patient #2 after they eloped and bring them back to the emergency department).

Interview on 03/21/24 at 06:53 PM with Staff (T) Registered Nurse, revealed that Patient #2 was put into room #19, directly across from the nursing station. An environmental sweep was done of the room and all potential harmful objects were removed. Patient #2 verbalized that they were not doing well, it was close to the anniversary of their daughter's death from a motor vehicle accident. Patient #2 was afraid of dying and leaving their son alone. Staff (T) did not recall if Patient #2 had a suicide plan. Patient #2 was not changed into hospital gown but still had their belongings with them. Approximately 90 minutes after arrival, Patient #2 asked if any staff had a phone charger to charge their phone so that they could call their son. Emergency department staff did not give Patient #2 a phone charger. Patient #2 then asked to use the restroom. Emergency department staff followed Patient #2 to the bathroom. Patient #2 proceeded to walk out of the emergency department. Staff (T) notified Staff (AA), Charge Registered Nurse. The charge nurse Staff (AA), Charge Registered Nurse stated that because Patient #2 was alert and oriented, they were allowed to leave if they wanted to.

Interview on 03/21/24 at 07:21 PM with Staff (Z) Registered Nurse, revealed they triaged Patient #2. Patient #2 spoke very "broken" (emotionally and jumping from topic to topic), and verbalized an attempting to commit suicide two years ago by hanging. Staff (Z) believed that the patient care technician brought Patient #2 back to a mental health room. Staff (AA), Charge Registered Nurse would instruct the patient care technician on what room to place a patient in. A high-risk suicidal patient would be taken back to the room by 1:1 (special constant) observation, wanded by security, and changed into hospital attire.

Interview on 03/21/24 at 07:31 PM with Staff (AA), Charge Registered Nurse revealed they did not recall any aspects of care or conversations with or about Patient #2. The triage nurse would update the change nurse about any high risk for suicide patients that arrived at the facility to allow the charge nurse to assign the appropriate room.

Findings #3:

Review of emergency department medical record for Patient #1 dated 03/11/24 revealed the following:
-At 11:15 AM, Staff (K), Physician, performed a medical screening examination after Patient #1 was found cutting their arm with a razor blade, which was able to be wrestled out of their arms by security. Patient #1 snuck a razor blade in past security their underwear. When Patient #1 got in the restroom, they used the razor blades to inflict multiple lacerations to their left extremity (arm). Patient #1 has done this in the past many times, sneaking in foreign bodies, and then lacerating themself in this facility. Patient #1 is quite agitated now despite multiple medications.

Interview on 03/20/24 at 02:19 PM with Staff (F), Security Officer, revealed that Patient #1 was brought in by Jamestown police. Staff (F), Security Officer, assisted with bringing Patient #1 back to room #126. Staff (F) assisted Jamestown police and Staff (G), Patient Care Technician, with changing Patient #1 into a gown. Once Patient #1 was changed, Staff (F) scanned Patient #1 with the handheld (wand) metal detector. Patient #1 was permitted to keep their underwear on while scanned. The wand did not go off when Patient #1 was scanned, indicating that Patient #1 did not have any metal objects on them that could be detected. Patient #1 asked to go to the bathroom and was told yes by Staff (G), Patient Care Technician. Patient #1 went into the bathroom alone. A few minutes later, Staff (G), Patient Care Technician, and Staff (F) opened the bathroom door and saw Patient #1 on the ground bleeding. Staff (F) asked Patient #1 to give them the razor blade. Patient #1 refused and attempted to put the razor blade to their neck. Staff (N), Security Officer, responded and was able to grab ahold of Patient #1's arm to prevent Patient #1 from harming themselves. Staff (F) was able to remove the razor blade for Patient #1's hand and give it to the clinical staff. Staff (F) is unsure of where Patient #1 had the razor blades. There were more razor blades in a plastic case on the sink.

Review on 03/21/24 of the document "Security Daily Event Log," indicated that on 03/11/24 at 10:41 AM, Patient #1's personal property was collected by Staff (N), Security Officer. At 10:50 AM, Staff (F), Security Officer, was present with a female Jamestown police office, and Staff (G), Patient Care Tech, while Patient #1 was changed into a safety gown. Staff (F) scanned Patient #1 with the handheld metal detector. At about 11:09 AM, Staff (F), Security Officer, discovered Patient #1 in the bathroom cutting their right arm with a razor blade.

Review on 3/20/24 of the product information for the "GARRETT Super Scanner V Wand," no date, revealed that periodic maintenance should include a daily check for battery condition, verification that that the Super Scanner V detects metal, and there are no loose or missing parts. A daily test standard can be established by using an object the size of a large coin. (No evidence was found to indicate daily checks on the wands is performed to ensure proper functioning).

Review on 03/21/23 of the security staff personnel files for Staff (F, N, O, P, Q, S, W, X, BB, CC, DD, and EE), revealed no evidence of initial and/or annual training or competency for the use of the GARRETT Super Scanner V handheld metal detector (wand).

Interview on 03/20/24 at 11:52 AM with Staff (B) Chief Nursing Officer, revealed there are no preventative maintenance wand logs. Staff do not perform a daily wand checks.

Interview on 03/20/24 at 02:19 PM, with Staff (F), Security Officer, revealed they were trained on how to use the wand when hired. Staff do not check the wand daily per manufacturers recommendations.

Interview on 03/20/24 at 02:30 PM, with Staff (L), Security Officer Manager, revealed that there is no formal training given to security officers regarding usage of the "GARRETT Super Scanner V (wand)" upon hiring or annually. There is no documentation for security staff indicating initial or annual "wand" training/competency. Periodic maintenance and daily operation checks are not conducted on any of the "wands."