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Based on observation, interview, record review, and policy review, the hospital failed to:
- Recognize and remove ligature (anything that can be used for the purpose of hanging or strangulation) risks related to uncovered ceiling air vents and a long phone cord in the Behavioral Health Unit (BHU).
- Provide a safe environment when contraband (items that are illegal, forbidden or that can be used to harm self or others) was found in the BHU day room, used by an unsupervised patient.
- Recognize potential risks, and repair or replace sharp objects related to uncovered, hanging wall thermostats, plastic soap dispensers, and non psychiatric-safe screws (could easily be removed by those at psychiatric risk) throughout the BHU.
- Recognize the potential for elopement (when a patient makes an intentional, unauthorized departure from a medical facility), repair an unstable wooden fence, and trim low hanging branches on an easily scaled tree in the BHU outdoor recreational area.
- Ensure crash carts (mobile cart which contains emergency medical supplies and medication) and defibrillators (a device that controls the heart by applying an electric current to the chest wall or heart) were checked every shift.
- Ensure a blanket warmer temperatures were checked daily, and at a safe temperature.
These failures had the potential to place all patients in an unsafe environment and at risk for poor patient outcomes

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 16 and the behavioral census was five.

See A-0144 for further details.

Based on observation, interview, record review, and policy review, the hospital failed to:
- Recognize and remove ligature (anything which could be used for the purpose of hanging or strangulation) risks related to uncovered ceiling air vents and a long phone cord, for two current patients (#7 and #8).
- Provide a safe environment when contraband (items that are illegal, forbidden, or that can be used to harm self or others) was found in the Behavioral Health Unit (BHU) day room, used by an unsupervised patient (#2).
- Recognize risks, and repair or replace sharp objects related to uncovered and hanging wall thermostats, plastic soap dispensers, and non psychiatric-safe screws (could easily be removed) throughout the BHU.
- Recognize the potential for elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and repair an unstable wooden fence and trim low hanging branches from an easily scaled tree in the BHU outside recreational area.
- Ensure crash carts (mobile cart which contains emergency medical supplies and medication) and defibrillators (a device that controls the heart by applying an electric current to the chest wall or heart) were checked every shift.
- Ensure a blanket warmer's temperature was checked daily, and at a safe temperature.
These failures had the potential to place all patients at risk for their safety and result in poor outcomes. The hospital census was 16.The BHU census was five, with three patients (#2, #8, and #20) admitted with suicidal ideations (SI, thoughts of causing one's own death).


Findings included:

1. Review of the hospital's nursing policy titled, "Suicide Risk Precautions," dated 01/2019, showed that the patient should be placed on continuous visual observation and the environment should be cleared of any potential harmful objects.

Review of the hospital's behavioral health policy titled, "Suicide Risk Assessment," revised 08/2018, showed that:
- General suicide risk factors could include a history of depression (extreme sadness that doesn't go away), history of a mood disorder (involves persistent feeling of sadness, or periods of feeling overly happy, or fluctuations from extreme happiness to extreme sadness), including bipolar disorder bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), presence of a suicide plan, and previous suicide attempts.
- There are three levels of observation that provide clear direction to staff for the supervision of the patient; Routine Checks, Frequent Checks, and Close Observation (CO).
- Routine Checks (Safety Checks) are the least restrictive, and involve intermittent observation of the patient to be recorded on the Patient Observation Record; they are to be completed at least every 15 minutes.
- Frequent Checks (line of sight [LOS]) are moderately restrictive, and involve intermittent observation of the patient; they should remain within LOS of the staff at all times, with no physical barriers between them; head, neck, and hands should be visualized; observations should be recorded on the Patient Observation Record at least every 15 minutes.
- CO (one-to-one [1:1]) would be the most restrictive, and involve continuous monitoring of the patient at all times, including toileting and showering; staff should remain within arm's reach at all times; observations should be recorded on the Patient Observation Record at least every 15 minutes.

Observation on the BHU, on 09/14/20 at 2:55 PM, showed:
- An uncovered, louvered, air-conditioning vent, which created an easily accessible ligature risk, in nine of the 10 patient rooms.
- Uncovered, unsecured, thermostats, in each of the 10 patient rooms and the hallway directly across from the nurses' station; two of which were hanging away from the wall by wires.
- Hard plastic soap dispensers hanging above the sink in each of the 10 patient rooms.

2. Review of Patient #7's History & Physical (H&P), dated 08/13/20 at 8:07 AM, showed that:
- He was admitted to the BHU on 08/12/20 at 5:07 PM, with a chief complaint of a recent decline in status due to paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones).
- His psychiatric history included drug abuse and dependence, and paranoid schizophrenia.
- He was to be observed every 15 minutes for safety, as ordered for his observation level.

Observation on the BHU, on 09/14/20 at 2:50 PM, showed that Patient #7 was sitting in a chair against the wall, directly under a telephone with an attached phone cord of at least 3 feet in length (ligature risk), and was not in constant observation of staff.

Review of Patient #8's H&P, dated 09/14/20 at 4:42 PM, showed that:
- He was admitted to the BHU on 09/14/20 at 4:15 PM, with suicidal ideations (SI, thoughts of causing one's own death), and a suicide plan.
- His psychiatric history included SI, substance (referring to legal or illegal drugs) and alcohol abuse, depression (extreme sadness that doesn't go away), and anxiety (a feeling of fear or worry experienced intermittently).
- He was to be observed every 15 minutes for safety, as ordered for his observation level.

Observation on the BHU, on 09/14/20 at 4:20 PM, showed that Patient #8 was standing, using the telephone with an attached phone cord of at least 3 feet in length, and was not in constant observation of staff.

Review of Patient #2's H&P, dated 09/08/20 at 1:05 PM, showed that:
- She was admitted to the BHU on 09/06/20 at 1:49 AM, with a chief complaint of SI.
- Her psychiatric history included bipolar disorder, depression, anxiety, and post traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock).
- She was to be observed every 15 minutes for safety, as ordered for her observation level.

Observation of the BHU dayroom, on 09/14/20 at 2:38 PM, showed that:
- Patient #2 was alone in the BHU dayroom.
- There were two television remote controls (contains batteries) lying on the table within her reach; she used them to turn off the television.
- There was a Styrofoam cup containing seven ink pens sitting on the table.
- There were open bookshelves containing 20 different board games and puzzles, with small game pieces inside (potential for ingestion).
- There were two clear plastic shoe boxes containing markers and crayons (potential for ingestion) sitting on the open bookshelves.
- On the counter to one side, there was a hard plastic pitcher of water, and a stack of small Styrofoam cups.
- No staff members were present to observe the patient.

During an interview on 09/16/20 at 9:05 AM, Staff I, Chief Nursing Officer (CNO), stated that when a patient was identified as having SI, she would expect staff to remove any items from the environment that could potentially be harmful, to include items such as those with cords; the phone, IV pumps, trash cans, bedside tables, and items made of hard plastics.

3. Observation on the BHU, on 09/14/20 at 2:50 PM, showed that:
- An enclosed outside recreational area, with a wooden 12-foot high fence along one edge, was attached to the BHU, and utilized by the patients and staff.
- One section of the wooden fence was loose at the top, and leaned into the yard.
- In one corner of the courtyard, there was a tree, approximately six feet from the wall of the building, with low hanging branches.

4. Even though requested, the hospital failed to provide a Crash Cart policy.

Observation on 09/15/20 at 9:30 AM, on the Medical Surgical (MS) floor, showed an adult crash cart and a pediatric crash cart. The adult crash cart had a defibrillator on top of the cart and both crash carts had clipboards with a daily crash cart checklist attached.

Review of the MS floor Adult and Pediatric Crash Cart Checklists showed the following:
- The crash cart was not checked on 04/01/20, 04/08/20, 04/13/20, 04/16/20, 04/17/20, and 04/18/20.
- The crash cart was not checked on 06/07/20, 06/10/20, 06/18/20, 06/23/20, 06/27/20, 06/28/20, 06/29/20, and 06/30/20.
- The crash cart was not checked on 05/12/20, 05/13/20, 05/18/20, 05/19/20, and 05/27/20 The crash cart was not checked on 07/01/20, 07/05/20, 07/07/20, 07/10/20, 07/11/20, 07/12/20, 07/13/20, 07/15/20, 07/17/20, and 07/28/20.
- The crash cart was not checked on 08/04/20, 08/20/20, and 08/31/20.
- The crash cart was not checked on 09/01/20, 09/02/20, and 09/03/20.
- There was no indication that the MS floor was closed on any of those days.

During an interview on 09/15/20 at 9:45 AM, Staff Y, Registered Nurse (RN), stated that the crash carts should be checked every shift. It was the charge nurse's responsibility to do this.

During an interview on 09/15/20 at 10:00 AM, Staff I, CNO, stated that her expectation of nursing staff was to check the crash carts every 12 hour shift. The MS floor had not been closed over the last six months.

5. Review of the hospital's policy titled, "Appropriate Temperature Settings for Blanket Warming Cabinets," dated 12/2018, showed the following:
- The temperature range of blanket or linen warming cabinets shall not exceed 130 degrees Fahrenheit.
- A temperature parameter sign is placed on the cabinet for quick reference.
- The temperature of the warming cabinet shall be checked on a daily basis and documented on the Warming Cabinet Temperature Daily Log sheet.

Observation on 09/14/20 at 1:45 PM, showed a blanket warmer in the Emergency Department (ED). A sign was posted on the blanket warmer that stated the temperature of the blanket warmer shall not exceed 130 degrees Fahrenheit.

Review of the hospital's ED Blanket Warming Cabinet Temperature Daily Log sheet for 2020 showed the following:
- In the month of April, the blanket warmer temperature was above 130 degrees, with temperatures of 138 to 144 degrees. The blanket warmer was not checked on 04/02, 04/03, 04/06, 04/07, 04/10, 04/11, 04/17, 04/22, 04/24, and 04/28.
- In the month of May, the blanket warmer was above 130 degrees, with temperatures of 138 to 145 degrees. The blanket warmer was not checked on 05/03, 05/05, 05/06, 05/11 through 05/14, 05/19, 05/20, 05/22, 05/27, 05/29, and 05/31.
- In the month of June, the blanket warmer was at 130 degrees for 3 days, the remaining days, the blanket warmer temperature was 132 to 144 degrees. The blanket warmer was not checked on 06/03 and 06/16.
- In the month of July, the blanket warmer was above 130 degrees, with temperatures of 131 to 144 degrees. The blanket warmer was not checked on 07/13, 07/17, 07/18, 07/21, 07/22, 07/24, and 07/28.
- In the month of August, the blanket warmer was above 130 degrees, with temperatures of 132 to 144 degrees. The blanket warmer was not checked on 08/05, 08/06, 08/10, 08/11, 08/13, 08/16, 08/20, and 08/27.
.- In the month of September, the blanket warmer was above 130 degrees, with temperatures of 138 to 143 degrees. The blanket warmer was not checked on 09/06 and 09/10.

During an interview on 09/14/20 at 2:00 PM, Staff B, ED RN, stated that the blanket warmer was checked daily and she thought the blanket warmer should not exceed 140 degrees.

During an interview on 09/14/20 at 2:30 PM, Staff C, Clinical Care Director and ED and Intensive Care Unit (ICU) Manager, stated that her expectation of staff was to check the blanket warmer daily, and if the temperature was above 130 degrees, maintenance should be called to adjust it. High blanket warmer temperatures could cause skin burns to patients.





39562

Based on observation, interview, record review, and policy review, the hospital failed to protect one suicidal (thoughts of causing one's own death) patient (#21) who eloped (when a patient makes an intentional, unauthorized, departure from a medical facility), when they did not follow the physician's order for one-to-one observation (1:1, continuous visual contact with close physical proximity) and failed to ensure staff were educated on all failures to prevent reoccurrence. These failures had the potential to affect all patients who presented to the hospital who were at risk for their safety or at risk for elopement. The hospital census was 16.

Findings included:

1. Review of the hospital's policy titled, "Risk for Elopement," revised 05/2018, showed that:
- Staff should identify patients at risk for elopement and attempt to prevent elopements.
- The definition of elopement had been defined as when a patient that is cognitively, physically, mentally, emotionally, and/or chemically impaired, wanders away, runs away, escapes, or otherwise leaves the hospital unsupervised, unnoticed, prior to their scheduled discharge.
- Elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) were to include placement of the patient to a room that would be easily monitored and away from the exits, the application of an orange armband and socks, and placement of an elopement sign on the patient's door.

Review of the hospital's behavioral health policy titled, "Suicide Risk Assessment," revised 08/2018, showed that Close Observation (CO, 1:1) would be the most restrictive, and involve continuous monitoring of the patient at all times. Staff should remain within arm's reach at all times and observations should be recorded on the Patient Observation Record at least every 15 minutes.

Review of the hospital's policy titled, "Physician/Provider Orders," revised 05/2018, showed that nurses are responsible for being informed about a patient's medical plan and their diagnosis, and that all physician orders are to be executed in a timely manner.

Review of the hospital's policy titled, "Behavioral Emergency (Code Orange)," revised 06/2020, showed that when a patient experiences a behavioral emergency, effort should be made to verbally de-escalate (reduction of the intensity of a conflict or potentially violent situation) the patient, and staff are directed to call the code extension "222" and to have a Code Orange paged on the intercom.

Review of the hospital's document titled, "Patient Observation Record," dated 07/2016, showed that the form used to document the patient's observations for safety, did not have a space or an indicator box that would identify the type or level of precautions that a patient was placed on, such as suicide precautions (SP, precautions that are taken to ensure patients are safe and free of self-injury or self-harm) or 1:1 observation.

Review of Patient #21's medical record, dated 09/18/20 at 2:05 AM, showed that:
- When law enforcement entered the residence, he was found with a clothesline wrapped several times tightly around his neck, and tied in a knot.
- He arrived to the Emergency Department (ED) with local law enforcement.
- His facial color was blue tinged.
- During his interaction with law enforcement, he made multiple statements about wanting to kill himself.
- He had prior attempts of suicide.
- His psychiatric history included bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks), anxiety(a feeling of fear or worry experienced intermittently), and depression.
- He told law enforcement that he had been trying to "kill the demons."
- He admitted that he was supposed to take medications for his psychiatric issues, but refused to do so.
- He eloped from the Intensive Care Unit (ICU) at 8:20 AM.

Observation on 09/14/20 at 1:50 PM, showed that Room 2 of the ICU, where Patient #21 was admitted into, was within 25-30 feet from the ICU exit door to the main hall. The unit was not a locked unit.

Review of Patient #21's physician orders, dated 08/19/20, showed that:
- At 3:05 AM, an order was entered to admit the patient to the ICU for observation, pending psychiatric evaluation.
- At 3:59 AM, an order for psychiatric observation level 1:1 was entered.
- At 4:39 AM, an order for SP was entered.

During an interview on 09/17/20 at 1:30 PM, Staff DD, Registered Nurse (RN), stated that:
- She had been the nurse that admitted Patient #21 to the ICU on 08/19/20.
- She was called in to work, to admit the patient and to be his 1:1 staff member.
- Patient #21 had made threats towards one of the law enforcement officers.
- Her understanding was that Patient #21 had been placed on a 96-hour hold (court-ordered evaluation by a behavioral specialist to determine if a person is safe to themselves and others).
- Patient #21 was difficult to have a conversation with. He would go off on a tangent (completely different thoughts), answered questions as if he had a split personality, and he would lower his voice with certain responses.
- During patient report, she had informed the oncoming day shift staff, Staff Z, RN; Staff L, RN; and Staff K, Patient Care Technician (PCT); that Patient #21 was on 1:1 observation.

During an interview on 09/14/20 at 2:14 PM, Staff K, PCT, stated that:
- She documented the 15 minute observations of Patient #21.
- She did not remain within arm's length of the patient, and went back and forth from a chair located in the patient's room door, to a chair at the nurses' desk, which was approximately 10 to 15 feet away.
- Patient #21 was "getting antsy" and paced.
- He verbalized that he "didn't want treatment," and that he was "going to leave."
- She was the staff member who called the Code Orange when the patient eloped, but she dialed "0" instead of the direct number "222" .

On 09/17/20, an attempt was made to interview Staff Z, RN, the nurse assigned to Patient #21 when he eloped, but it was unsuccessful.

During an interview on 09/14/20 at 1:55 PM, Staff L, RN, Charge Nurse (CN), stated that:
- In the ICU, they utilized rooms 2 or 3 for psychiatric patients, since they were directly across from the nurses' desk.
- Psychiatric patients would normally be LOS, with constant visualization, or occasionally they would be assigned a 1:1 staff member.
- She did not know if Patient #21 had an order for 1:1.
- He was identified as an elopement risk, and had been placed in a gown, with an orange wristband and orange socks applied, and had a sign that indicated he was an elopement risk on his door.
- She had left the unit to go to the lab, and that was when Patient #21 exited through the unit door. She felt that he had watched staff go in and out of the unit, and saw her exit as an opportunity to leave.

During an interview on 09/15/20 at 3:55 PM, Staff CC, Doctor of Osteopathy (DO), stated that:
- He remembered that Patient #21 had been brought to the ED by local law enforcement after he wrapped a cord several times around his neck.
- There were occasions when a psychiatric patient would be admitted to the ICU initially.
- A 1:1 would be ordered for a reason, and he would expect staff to follow the order.
- He defined 1:1 observation as when the staff member remained in direct, close proximity to the patient. This would be for a patient he had great concern for their safety, and should be very closely guarded.

During an interview on 09/16/20 at 9:05 AM, Staff I, Chief Nursing Officer (CNO), stated that:
- A Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) had been completed related to Patient #21's elopement.
- The patient's Observation Form did not reflect the type of observation that was ordered.
- There was a 1:1 observation level order for Patient #21.
- Hospital administration did not recognize the patient was ordered to be observed 1:1 , or that staff had failed to follow the order and the hospital policy.
- She would have expected staff to remain within arm's length of a patient who had an order for 1:1 observation.
- There was some delay with the start of education related to the RCA findings.
- Hospital staff were not educated about 1:1 observation after Patient #21 eloped.