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Based on medical record review, document review, video footage review, and staff interview it was determined the Director of Behavior Health failed to ensure patient safety checks were completed as ordered, and patients were removed from the area of a suicide patient. This failure has the potential for all patients to be at risk for psychological harm and the potential for self-harm (See Tag A 144).

As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 07/12/22 at 12:55 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified by the State Survey Agency on 07/13/22 at 11:40 a.m.

The following interventions were implemented to resolve the IJ:

All staff will be educated on their roles during a code blue (Cardiopulmonary resuscitation) to ensure all staff are assigned to continue patient safety checks and to ensure patients are moved to an area away from the code blue.

Mock code blues and audits of video footage will be conducted to ensure all safety checks are completed as documented.

Training will begin immediately, and all nursing staff will be educated prior to the beginning of their shift.

Based on medical record review, document review, review of video footage, and staff interview it was determined the Director of Behavior Health (DBH) failed to ensure that safety checks were conducted, and patients were removed from the area of a patient who committed suicide, for eleven (11) of twelve (12) patients (patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) during a code blue Cardiopulmonary resuscitation (CPR). This failure has the potential for all patients to cause self-harm and has the potential for all patients to have psychological trauma from observing CPR and a death that may prolong their hospitalization.

Findings include:

A review of the policy titled "Observations," last revised 01/24/22, states in part: "Levels of observation: Routine observations, all patients are placed on routine observations, all patients will be visually observed a minimum of every 15 minutes. Document patient location and observable behavior, engage briefly with patient as frequently as possible during routine observation."

A review of the medical record for patient #2 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #3 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #4 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #5 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #6 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #7 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #8 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #9 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #10 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #11 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of the medical record for patient #12 revealed the patient was ordered standard safety precautions that were to be conducted every fifteen (15) minutes. On 06/02/22 from 5:15 p.m. through 6:00 p.m., all safety checks are documented as completed.

A review of video footage of patient #1 was conducted on 07/13/22 at 8:00 a.m. in the presence of the Director of Regulatory Compliance (DRC) and Security on a large screen monitor. On 06/02/22 at 5:29:24 p.m., patient #2 looked at patient #1's door and went to the nursing station and spoke to Patient Care Technician (PCT) #1. PCT #1 went to patient #1's door at 5:31 p.m. and could not get the door open. PCT #1 started down the hall and patient #2 said something to Registered Nurse (RN) #1. RN #1 went to patient #1's door and shoved it open. RN #1 comes out of patient #1's room and runs to the nursing station and then runs back to patient #1's room. A crash cart is brought into patient #1's room. Many health care workers are seen coming onto the unit while the unit's locked door is held open by Security. Security remains at the open door. PCT #1 can be seen taking equipment into patient #1's room. PCT #2 can be seen leaning against a wall with their face into the wall and then walking to the nursing station with their arms and head leaning on the nursing station. PCT #1 is seen at the nursing station with PCT #2. Patients #2 and 3 remain in the hallway. At 5:44 p.m., patient #1 is brought into the hallway on a carrier, and you can see CPR being done in the hallway. Patients #2 and 3 remain in the hallway at the nursing station and are looking down the hall at patient #1. PCT's #1 and 2 are at the nursing station and wandering the hall from the nursing station to the first door on the left from the nursing station. At 5:55 p.m., CPR is stopped. Patient #1 is taken back into their room. At 5:57 p.m., patient #1 is brought out of the room with a sheet placed over their body. Patients #2 and 3 remain in the hallway. At 6:00 p.m., patients #2 and 3 are still in the hallway as patient #1 is removed from the unit. No safety checks were completed during the review of the video. It should be noted that no video was saved of the hallway with the common room/dining area.

An interview was conducted on 7/13/22 at 8:10 a.m. with the DRC during the review of the video footage and the DRC agreed patients #2 and 3 were not being monitored. The DRC requested to be able to speak with the DBH to see if the other patients were being monitored in the dining area.

An interview was conducted on 07/13/22 at approximately 9:15 a.m. with the DRC. The DRC texted the DBH and showed the surveyor the return text in which the DBH concurred there was only one (1) patient (patient #13) in the dining room with another staff member. The DRC concurred PCT's #1 and 2 did not complete their safety checks of the other patients on the unit during the code blue. The DRC further concurred all patients should have been moved to another area, most likely the dining area, to prevent them from seeing the patient.

Based on document review and staff interview it was determined the hospital failed to ensure patient safety measures were added to the Quality Assurance/Performance Improvement (QA/PI) meetings. This failure has the potential for substandard patient care (See Tag A 286).

As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 07/12/22 at 12:55 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified by the State Survey Agency on 07/13/22 at 11:40 a.m.

The following interventions were implemented to resolve the IJ:

When a Root-Cause-Analysis (RCA) is completed due to a patient event or a near miss, the RCA summary will be presented at the next scheduled QA/PI meeting by the Regulatory Compliance Coordinator. The QA/PI meeting minutes will reflect discussion and any course of action/next steps that are identified to ensure the safety of the patients.

The RCA will remain an agenda item at the monthly QA/PI meetings; where applicable, audits, changes to policy/process, and any other pertinent details will be presented to track and analyze until sustained consistent improvement is achieved.

A. Based on document review and staff interview it was determined the hospital failed to ensure falsified/patient safety checks were being tracked, trended and analyzed in the Quality Assurance/Performance Improvement (QA/PI) program. This failure has the potential for all patients ordered safety checks to not receive them, which could ultimately lead to their death.

Findings include:

A review of QA/PI meeting minutes that was conducted on 07/07/22 revealed no safety analysis was completed on falsifying documentation of patient safety checks.

Review of Patient Care Technician (PCT) #2's 'Staff Performance Evaluation,' dated 03/31/22, states in part: "[States employees name] is familiar with duties ... however where performance falls short is when there has been periods of forgetfulness or disregard. These lapses in attention and memory pose significant safety risk for both staff and patients. On occasion the rounds board [patient safety rounding sheet] was placed on the counter [states employees name] exited the unit to let in a visitor. During that time a patient eloped behind [them]. The patient hid behind the locker set, was in the sallie port and was able to hide behind the lockers until found by another person ... it should be noted [states employees name] did not realize the patient was not on the unit even though this should have been picked up in rounds."

Review of PCT #2's human resource record revealed the employee was disciplined for falsifying documentation of patient safety checks on 04/04/22 and 06/08/22.

A telephone interview was conducted with the Chief Executive Officer on 07/13/22 at 8:30 a.m. When asked why the PCT's falsifying documentation of safety checks was not monitored in the QA/PI program, they stated in part, "I don't know why, but it is a good suggestion."

An interview was conducted with the Director of Quality on 07/13/22 at 9:00 a.m. When asked why these safety measures were not brought into the QA/PI for safety measures, they stated in part, "I didn't know anything about it or it would've been monitored."

An interview was conducted with the Director of Regulatory Compliance on 7/13/22 at 9:30 a.m. and when asked why these safety measures were not brought into the QA/PI, they stated in part, "Because that is more of a human resource issue." They agreed it was also a safety issue.

B. Based on document review, medical record review, and staff interview it was determined the Quality Assurance/Performance Improvement (QA/PI) program failed to monitor suicides attempted in the hospital in ten (10) of twelve (12) patients (patients # 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) and failed to monitor suicides committed in the hospital in one (1) of one (1) deaths due to suicide. This failure has the potential for a systemic breakdown of information.

Findings include:

A review of the Root-Cause-Analysis (RCA) conducted on 07/03/22 revealed the RCA showed patient safety indicators were falsified and a patient committed suicide.

Review of QA/PI revealed no analysis of the suicide was reported to the QA/PI in the 07/07/22 quarterly meeting.

Review the medical record for patient #1 revealed on 06/02/22 the patient committed suicide by hanging and expired.

A telephone interview was conducted with the Chief Executive Officer on 07/13/22 at 8:30 a.m. When asked why the death was not reported to the QA/PI program, they stated in part, "I don't know why, but it is a good suggestion."

An interview was conducted with the Director of Quality on 07/13/22 at 9:00 a.m. When asked why the death was not reported in the 07/07/22 meeting, they stated in part, "Because Senior Management took it over." They concurred there was no documentation in the QA/PI for the patient's death or patient safety checks not being completed.

Based on medical record review, document review, and staff interview it was determined the Director of Nursing failed to ensure that patients admitted with suicidal ideations were given an accurate Columbia Suicide Severity Rating Scale (C-SSRS)(See Tag A 395).

As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 07/12/22 at 12:55 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified by the State Survey Agency on 07/13/22 at 11:40 a.m.

The following interventions were implemented to resolve the IJ:

All patients who are assessed for admission to the Behavioral Health Unit by a crisis worker will be given the Shortened-ED (Emergency Department) version of the C-SSRS. If a patient scores as high-risk, the patient will be immediately placed on or continued one-on-one (1:1) observation until a psychiatrist and/or attending physician has assessed for discontinuation of that observation.

All patients will receive a 'Patient Health Questionnaire' (PHQ-9) screening and lifetime/recent C-SSRS upon admission. If a patient scores as high-risk, the physician will be notified of the risk level and will determine appropriate precautions and/or observations. Patients will be reassessed every twelve (12) hour shift using C-SSRS Questions #2 and 6. If the patient answers "No" to Question #2, the nurse will ask Question #6; if the patient answers "Yes" to Question #2, nursing will ask Questions #3, 4, 5 and 6. A flowsheet will be added to each nursing shift note. Prior to discharge, the patient will have an updated C-SSRS. Training will begin immediately, and all nursing staff will be educated prior to the beginning of their shift.

C-SSRS directions are as follows: If Yes to Question 2, ask Questions 3, 4, 5 and 6. If No to Question 2, go directly to Question 6.

A. Based on medical record review, document review, and staff interview it was determined the nursing staff failed to completed a Columbia Suicide Severity Rating Scale (C-SSRS) on one (1) of one (1) patients (patient #1) who committed suicide. This failure has the potential, and did lead to, the death of the patient.

Review of the medical record for patient #1 revealed no C-SSRS was completed on 05/29/22. On 5/30/22, the only Question answered was #2. On 06/01/22, the only Question answered was #2. It should be noted C-SSRS directions are as follows: If Yes to Question 2, ask Questions 3, 4, 5 and 6. If No to Question 2, go directly to Question 6.

A review of the document titled "Job Description Vice President, Nursing/Chief Nursing Officer," states in part: "Position Summary: Plans, organizes, directs and evaluates nursing care in assigned areas of responsibility. Coordinates with President/CEO to direct and evaluate nursing care throughout the hospital. Maintains close relationships with physicians and other customers to assess services and determine the need for change or new programs to achieve the institution's objectives. Provides leadership at the executive level coordinating nursing, direction and administration of operations."

A review of the document titled "Depression and Suicide Risk Screening," last revised 2/29/20, states in part: "The PHQ-9 [Patient Health Questionnaire] will be used to screen for depression, and Question #9 will screen for suicidal ideations ... Score of 15-27 = moderately severe to severe depression. Clinical Practice Guidelines auto populated Physician Alert (attending) document in EMR [electronic medical record]. Note on AVS [after visit summary] for PCP [primary care physician] after discharge ... Complete PHQ-9 as soon as patient able to answer ... The patient will be placed in a private room ... the patient will be monitored one-on-one (1:1) within arms reach."

An interview was conducted on 07/11/22 at 7:50 a.m. with the Nursing Supervisor. When asked when a C-SSRS should be conducted, they stated, "Every shift."

An interview was conducted on 07/11/22 at 10:00 a.m. with the Director of Behavior Health (DBH). When asked how often a C-SSRS needs to be completed, they stated, "At least every shift and when changes are seen in patients."

An interview was conducted on 07/12/22 at 1:00 p.m. with Physician #2. When asked how often a C-SSRS is to be completed, they stated in part, "Daily and when the patient's needs change." When asked if they had been notified by the nurse that the patient was isolating after meals instead of watching television, which was a change in his psychosocial assessment, they stated, "No."

A telephone interview was conducted on 07/12/22 at 3:30 p.m. with the DBH and they concurred that not all of patient #1's C-SSRS was completed.

B. Based on medical record review, document review, and staff interview it was determined that nursing failed to ensure a change in condition/change in a patient's daily activities was reported to the patient's physician in one (1) of thirteen (13) of medical records reviewed (patient #1). This failure led to the death of one (1) patient and has the potential for harm to all patients.

An interview was conducted with PCT #1 on 07/11/22 at 1:20 p.m. When asked to explain the patient's behavior on the day of their death, they stated in part, "Normally the patient goes to breakfast and then watches TV [television] for twenty to thirty (20-30) minutes and then goes to their room. They do the same thing for every meal and then watches TV for twenty to thirty (20-30) minutes and then goes to their room. That day, the patient ate breakfast, lunch and dinner, but they never went to watch TV. [Patient #1] told everyone [they] wanted to die and [they] isolated [themself] most of the time."

A telephone interview was conducted on 07/11/22 at 2:30 p.m. with Registered Nurse #1. When asked to explain the patient's behavior the day of their death, they stated in part, "I assessed [them] in the a.m. [They] were depressed but contracted to safety. [Patient #1] normally spends a lot of time in front of the TV, but not that day. [They] would get [their] tray, eat and then go to [their] room and shut the door.

A telephone interview was conducted with Physician #2 on 07/12/22 at 1:00 p.m. When asked if they had been notified the patient had a change of their psychosocial/activities the day of patient #1's death, and explained the patient had stopped watching TV, which they seemed to enjoy, and was only eating his meals and going to their room and shutting their door, they stated in part, "No, I was unaware in that change. No one contacted me to tell me." When asked if they had been notified of the psychosocial/activity change would that have increased their safety checks or have made the patient a one-on-one (1:1), they stated in part, "Many things can be changed in hind-sight, but yes, I would've probably changed [patient #1's] safety rounds."

A telephone interview was conducted on 07/12/22 at 3:30 p.m. with the DBH. They concurred the physician should have been notified of the alteration in the patient's activities.

Based on observation, document review, and staff interview it was determined the hospital failed to provide a sanitary environment in the clean utility room and the laundry room on the Behavior Health Unit. This failure has the potential for all patients to have cross-contamination when using needed equipment.

A tour of the Behavior Health Unit was conducted on 07/11/22 at approximately 10:50 a.m. with the Director of Regulatory Compliance (DRC). During the tour in the unit's clean utility room, the following was noted: one (1) intravenous (IV) machine had no plastic bag or a clean sticker, two (2) blood pressure machines were noted with no plastic bag or a clean sticker, and one (1) Coleman Cooler was sitting in the floor. In the laundry room the following was noted: beside of board games there was shampoo, conditioner and soap bottles and near the hopper (a toilet like machine used to clean bedpans, urinals, etc.) there were four (4) blood pressure machines with garbage bags over them, one (1) walker with garbage bags over it, one (1) wheelchair with garbage bags over it, three (3) oxygen concentrators with garbage bags over them, and one (1) portable potty with garbage bags over it. The garbage bags are used after the equipment is cleaned.

A review of the policy titled "Disinfection of Noncritical Patient Care Equipment Procedure," last revised 01/06/22, states in part: "Once the equipment has been cleaned, place a CLEAN sticker where it is readily visible for the next user, and store the equipment as usual."

An interview was conducted during the tour on 07/11/22 at approximately 11:15 a.m. with the DRC. They concurred the equipment in the clean room should have been marked clean and the clean products in the dirty room should not be in the laundry room.