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Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to provide a 1:1 sitter for a high risk patient. (A-144 A)

2. The Hospital failed to ensure the Gero Psychiatric Unit (GPU) was free from ligature risks to prevent potential, serious harm to patients. (A-144 B)


The immediate jeopardy was identified on 3/21/2023, due to the Hospital's failure to ensure that care was provided in a safe setting. The Hospital failed to ensure the patient rooms on the geriatric behavioral health unit (GPU) were free from ligature risks, and failed to monitor patients at high risk for elopement appropriately to prevent serious harm. The IJ was cited at 42 CFR 482.13, Patient Rights, and was announced on 3/22/2023 at 9:00 AM, during a meeting with the Chief Executive Officer, the Interim Chief Nurse Executive and the Quality Management Director. The IJ was not removed by the survey exit date of 3/22/2023.

A. Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #1) who jumped out of a window, The Hospital failed to ensure that care was provided in a safe setting by failing to provide a 1:1 (staff: patient) sitter for a high risk patient.

Findings include:

1. On 3/21/2023, the Hospital's policy titled, "Patients Requiring Constant Surveillance," not dated, was reviewed. The policy required, "Sitters are also utilized for patients that are restless, and trying to remove medical equipment ... Assure that one-to-one observation is maintained ..."

2. On 3/20/2023, Pt. #1's clinical record was reviewed. Pt. #1 was transported by ambulance to the Emergency Department (ED) for seizure disorder on 3/12/2023 at 4:31 AM. At 4:45 AM. Pt. #1 was triaged and found "alert ...appropriate ... cooperative". A "safety screening" included, "suicide ideation description: none".

- Pt #1 was admitted to the Hospital's 3 East Observation Unit with a diagnosis of seizures.

- Pt. #1's History and Physical (H&P), dated 3/14/2023 at 3:53 AM, included, a history of seizures with altered mental status, non-compliant with medications, and "drinks ETOH [alcohol] heavily". The H&P also included, "Psych: Anxiety, Addictions, Depression, Panic".

- A nursing note on 3/15/2023 at 11:20 AM, included, "Patient started to become delusional, hearing voices, yelling and showing aggressive behavior. The patient removed his IV cannula and his telemetry. Security was called for support and safety. The transporter came to help but the patient tried to harm the transporter and security by pointing ... a sharp metal object. The patient ran, tried to leave the hospital premises and then he lost the telemonitor. The security was able to hold the patient in their office. Police were called and reported the incident ... [A Nurse Practitioner, NP #1, wrote] orders for a psych consultation ..."

- A nursing note on 3/15/2023 at 1:46 PM, included, "Patient was transferred back to the floor and placed in a private room [room 319]. Patient is still aggressive and restless... [The Nurse Practitioner, NP #1] ordered for sitter and 4 point restraints due to harm to self and others. A sitter was assigned to Pt #1.

- A restraint order, dated 3/15/2023 at 2:14 PM, required "violent restraint," for 4 hours, with "leather/hand wrist," due to "harm to self, harm to others, interferes with treatment, and removal of medical devices". Bilateral arm and leg restraints were applied at 2:00 PM and restraint removed at 3:17 PM.

- Nursing notes on 3/15/2023 at 9:15 PM, included, "Patient is transferred to [room] 308-1 to join with a patient in 308-2, having a sitter."

- A nursing note [E #4] on 3/15/2023 at 9:30 PM, included, "This writer [E #4] was in nurses station. Heard somebody screaming too loud. This RN went to patient's room. Sitter states my patient jumped over [out] the window. (Window facing parking lot...) My charge nurse called security office and nursing supervisor. Patient was picked up by security ... and brought to ER ..."

- An ED progress note on 3/15/2023 at 10:44 PM, included, "X-rays show bilateral commuted tibia [lower leg bone], fibula, [lower leg bone] and ankle fractures."

3. An Incident Report dated 3/15/2023 at 9:30 PM, included Pt. #1's "Patient jumped out of window, in spite of sitter". The Report include that a severe fracture injury occurred and the patient's mental status was a factor.

4. On 3/20/2023 at 1:30 PM, an interview was conducted with Pt. #1's Sitter (E #3) during the 3/15/2023 7:00 PM to 3/16/2023 7:00 AM shift. E #3 stated that she was already sitting for another patient (Pt. #3) in room 308 when Pt. #1 was transferred into room 308, at approximately 9:00 PM. The first patient, Pt. #3, "was trying to climb out of bed" and E #3 was trying to calm down Pt. #3. Pt. #1 asked E #3 to call someone to come visit him, thinking it was 5:00 PM. E #3 told Pt. #1 it was 9:10 PM and visiting hours were over. Pt. #1 began pacing and getting closer to the door. E #3 stated that she was afraid of Pt. #1 even though Pt. #1 was "small and thin". Pt. #1 was "nervous" ... "anxious" and it "didn't set well" that E #3 was his Sitter. E #3 told Pt. #1 to "come back in here, " when Pt. #1 got close to the door. E #3 called for help, but "in the blink of an eye," Pt. #1 left the room (308), opened the hallway window, just outside of room 308, and "climbed out [through the window] feet first". Pt. #1 fell 3 floors to the blacktop parking lot below.

- E #3 stated that sometimes she is assigned to watch 2 patients at a time and there is no problem if they can be controlled. E #3 stated that she works in an environmental service (housekeeping) position, but has had Sitter Training. E #3's personnel file was reviewed on 3/22/2023, and E#3 completed Pattient Care Companion (sitter)training on 8/29/2022.

6. On 3/21/2023 at 1:00 PM, an interview was conducted with the Interim Chief Nurse Executive (E #1). E #1 stated that Pt. #1 was determined to be at high risk when he attempted to abscond from the Hospital on the morning of 3/15/2023. E #1 stated that Pt. #1 was a high risk for elopement and that high risk patients should be with a 1:1 Sitter.


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B. Based on document review, observation, and interview, it was determined that for 11 of 11 (450 -460) patient rooms, the Hospital failed to ensure that care was provided in a safe setting by failing to ensure the Gero Psychiatric Unit (GPU) was free from ligature risks to prevent potential, serious harm to patients. This potentially affected all current and future suicidal patients.

Findings included:

1. On 3/21/2023, the CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. On 3/20/2023, the Hospital's policy titled, "Observation Levels (revised 1/2016)" was reviewed and indicated, "...It is the policy of the GPU that staff monitoring is instituted to maintain the safety of each patient and provided by a system of progressive intensity of patient observation and oversight. ..." The policy did not require room entrance doors to be kept open while patients were in rooms or locked when not in use on the psychiatric unit, and lacked any patient safety measures to mitigate the ligature risk posed by the patient room entrance doors.

3. On 3/20/2023 from 11:00 AM to 11:30 AM, an observational tour of the GPU was conducted. The unit had 11 rooms with a capacity for 15 patients, and the following ligature risks were identified:
- Movable, electric beds with wheels were present in all 11 rooms (totaling 15 beds). Each beds had 4 half side rails (2 on each side with openings which could be used as anchor points). Each bed contained a 42-inch electrical, power cord which plugged into the wall socket, and an additional 42-inch cord used to lock the bed to the floor.
-The rooms had metal plates with hooks outside of the bathrooms which did not move freely/could not be pulled down when heavy pressure applied.
- The patient room entrance doors and door frames were square, and the doors reached the top of the door frames.
During the tour, the registered nurse (E#7) was interviewed and stated that patients are allowed to be in their rooms with the door closed.

There were 7 patients on census on the GPU on 3/20/23, of which 2 patients (Pt's. #11 and #12) were on SP (suicide precautions). SP required safety rounds to be conducted every 15 minutes to prevent suicide.

4. The environmental assessments were reviewed on 3/21/2023 and did not identify any ligature risks. There were no plans to fix beds, doors, or hooks.

5. An interview was conducted with the Program Director (E#6) for GPU on 3/21/2023 at approximately 11:30 AM. E #6 stated that the ligature risks related to the moveable beds with cords and side rails, entrance doors and the hooks were not identified.