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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.614, PATIENT RIGHTS, was out of compliance.

C-2523 The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure items which could be used for harm to self or others including ligature risks (anything which could be used to create an attachment point such as a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms and the restroom and patients with acute psychiatric complaints were monitored according to policy. This failure was identified in four of five patients reviewed who presented with psychiatric complaints. (Patients #2, #6, #13, #17)

Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure items which could be used for harm to self or others including ligature risks (anything which could be used to create an attachment point such as a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms and the restroom and patients with acute psychiatric complaints were monitored according to policy. This failure was identified in four of five patients reviewed who presented with psychiatric complaints. (Patients #2, #6, #13, #17)

Findings include:

Facility policies:

According to the Suicide Screening and Follow-Up policy, by implementing routine screening practices in all patient care settings, the facility will improve the identification of those at risk for suicide to reduce suicide in all patient populations. Emergency Department (ED) staff will complete suicide screening for patients over 12 years of age at every visit unless the patient is unable due to the severity of their medical condition or cognitive state. If a patient screens high risk, clinical staff will verbally communicate the score to the patient ' s provider.

According to the Depression Screening and Follow-up policy, ED staff will aim to complete depression screening for patients over 12 years of age at every visit per clinician discretion, unless the patient is unable. The facility aims to identify those patients suffering from depression and other mental health disorders to reduce suicide in all patient populations.

According to the Mental Health Hold policy, any person deemed to pose a threat to themselves or others shall be placed in an exam room as close to the nursing station as possible. Equipment, linen, or supplies the patient could harm themself or others with should be removed from the room. Patients placed on a 72-hour hold after admission must be placed on one-to-one (1:1) observation in order to prevent the patient from leaving the hospital from an unsecured unit.

According to the Nursing Standards of Patient Care policy, the purpose is to ensure that each patient receives appropriate nursing care and interventions, relevant to meet the patient ' s needs. Each patient will receive nursing care and interventions to achieve the desired outcome for the patient. Each patient will be provided nursing care based on the identified needs and diagnosis, have a plan of care that respects their rights, will have nursing care and interventions available to meet their needs, will receive individualized care and interventions based on identified needs, will receive nursing care and interventions at the most beneficial or necessary time, will receive nursing care and interventions to achieve the desired outcome for the patient, will be provided safety measures and nursing care designed to reduce the risk of an intervention, reduce the risk in the care environment, and will receive respectful and caring nursing service.

Reference:

According to the Patient Rights and Responsibilities handout, the facility will treat patients with respect, in a safe setting.

1. The facility failed to remove ligature risks from patient care rooms and failed to monitor suicidal patients according to policy.

A. Observations revealed patient rooms and the patient restroom in the emergency department (ED) contained ligature risks as well as other items which could be used for harm to self or others.

i. Observations conducted on 4/29/24 at 3:35 p.m. and 5/2/24 at 9:14 a.m. revealed the patient rooms in the ED contained call lights connected to the wall by a cord. Patient rooms also contained monitoring equipment with attached cords, as well as examination equipment affixed to the wall. The patient bathroom in the ED contained a pull cord affixed to the wall for patients to use if they needed assistance, and a trash can which contained a plastic liner and visible waste.

B. Document Review

i. The facility was unable to provide evidence of policies and procedures pertaining to keeping psychiatric patients in the ED safe.

a. Upon request on 5/1/24 at 8:55 a.m., the facility revealed they did not have a suicide precautions protocol or policy. At this time, an interview was conducted with ED nurse manager (Manager) #2 who stated there was not a standard procedure for patients admitted to the ED for suicidal (wanting to kill oneself) ideations (SI).

b. Upon request on 5/1/24 at 8:55 a.m., the facility revealed they did not have a policy on sitters for psychiatric patients in the ED. At this time, an interview was conducted with Manager #2 who stated there was no ED policy for sitters and staff struggled to find sitters for psychiatric patients.

ii. A review of medical records revealed patients with psychiatric complaints, including those who wanted to harm themselves or others, had unmonitored access to items with which to harm themselves and others in the rooms and their belongings and also were not continuously monitored by staff during their time in the ED.

a. A review of Patient #2's medical record revealed Patient #2 was a 17-year-old, admitted to the ED on 2/5/24 for depression. The record revealed Patient #2 had a long history of depression and had been uncommunicative over the past several days according to their parent. The triage note on 2/5/24 at 9:20 p.m. failed to reveal evidence the Columbia Suicide Severity Rating Scale (C-SSRS) which evaluated suicide risk had been performed, although Patient #2's parent was afraid the patient was suicidal. In the triage Suicide Risk section, the nurse wrote "unable to obtain" without any additional documentation.

This lack of suicide screening was in contrast to the Suicide Screening and Follow-Up policy which read, ED staff completed suicide screening for patients over 12 years of age to reduce the risk of suicide. From 2/5/24 at 9:05 p.m. to 2/6/24 at 8:46 a.m. (11 hours and 19 minutes), until the patient was transferred to an inpatient psychiatric facility, Patient #2 had access to their personal belongings and remained in their own clothing which allowed for unmonitored access to items which they could use for harm to self or others. The record also did not reveal evidence the room was made safe for Patient #2 or continuous patient monitoring occurred by staff during their time in the ED.

b. A review of Patient #6's medical record revealed Patient #6 was a 12-year-old, admitted to the ED on 4/2/24 for homicidal (wanting to kill others) ideations (HI). Patient #6 had a history of HI and attempts, along with a history of self-injury. The record revealed Patient #6 had been placed on a mental health 72-hour hold (M1) by a behavioral health center before arriving at the facility. From 4/2/24 at 12:24 p.m. to 4/3/24 at 8:38 a.m. (20 hours and 14 minutes), Patient #6 had access to their personal belongings and remained in their own clothing. The record also did not reveal evidence the room was made safe for Patient #6 which allowed for unmonitored access to items which they could use for harm to themselves or others. Additionally, the record revealed Patient #6 was monitored by their parents and failed to reveal staff involvement in continuously monitoring the patient during their time in the ED.

This failure to remove belongings and lack of 1:1 monitoring by staff was in contrast to the Mental Health Hold policy which read, equipment, linen, or supplies the patients could use for self-harm were to be removed from the room and patients on a 72-hour hold were placed on 1:1 observation to prevent the patient from leaving the hospital.

c. A review of Patient #13's medical record revealed Patient #13 was a 44-year-old, admitted to the ED on 11/25/23 after a suicide attempt. The C-SSRS performed during triage on 11/25/24 at 12:35 a.m. revealed Patient #13 was at high risk for suicide. The record revealed Patient #13 was placed on an M1 hold on 11/25/23 at 2:06 a.m. due to being a danger to themself and had multiple plans to end their own life. Until 11/25/23 at 11:04 a.m. (eight hours and 58 minutes after the M1 hold was placed), when they were transferred to an inpatient psychiatric facility, Patient #13 had access to their personal belongings and remained in their own clothing. The record also did not reveal evidence the patient room or bathroom was made safe for Patient #13 or that staff continuously monitored Patient #13 during their time in the ED which allowed for unmonitored access to items which they could use for harm to self or others.

This failure to remove belongings and lack of 1:1 monitoring by staff was in contrast to the Mental Health Hold policy which read, equipment, linen, or supplies the patients could use for self-harm were to be removed from the room and patients on a 72-hour hold were placed on 1:1 observation to prevent the patient from leaving the hospital.

d. A review of Patient #17's medical record revealed Patient #17 was a 39-year-old, admitted to the ED on 1/17/24 for suicidal ideations. The C-SSRS performed during triage on 1/17/24 at 6:30 p.m. revealed Patient #17 was at high risk for suicide. The record revealed Patient #17 was placed on an M1 hold on 1/17/24 at 10:00 p.m. due to being a danger to themself and had plans to end their own life. Until 1/18/24 at 8:10 a.m. (10 hours and 10 minutes after the M1 hold was placed), Patient #17 remained in their own clothing and had access to their personal belongings, including a box of nicotine pouches, a "sleep mask/gator," and a charger for their phone. The record also did not reveal evidence the patient room or bathroom was made safe for Patient #17 or that staff continuously monitored Patient #17 during their time in the ED which allowed for unmonitored access to items which they could use for self-harm. Additionally, on 1/18/24 at 9:52 p.m., the nursing rounding notes revealed the patient walked to the cafeteria for food.

This failure to remove belongings for more than 10 hours after the M1 hold was placed and the lack of 1:1 monitoring by staff was in contrast to the Mental Health Hold policy which read, equipment, linen, or supplies the patients could use for self-harm were to be removed from the room and patients on a 72-hour hold were placed on 1:1 observation to prevent the patient from leaving the hospital.

This review of medical records for Patients #2, #6, #13, and #17 was in contrast to the Patient Rights and Responsibilities handout and the Nursing Standards of Patient Care policy which read, the facility treated patients respectfully, in a safe setting. Each patient received appropriate nursing interventions to achieve the desired outcome. Each patient had a plan that respected their rights and was provided safety measures and nursing care designed to reduce the risk of intervention and reduce risk in the care environment.

C. Interviews

i. On 4/29/24 at 4:21 p.m. and on 5/1/24 at 11:04 a.m., interviews were conducted with registered nurse (RN) #1. RN #1 stated patients in the ED were screened with the C-SSRS to ensure they were not suicidal. They stated if a patient presented with suicidal ideations and was screened as high risk on the C-SSRS, the patient's room would be cleared of any unnecessary medical equipment and cords, and the patient's belongings would be taken away to ensure patient safety, which was in contrast to a review of the medical records for Patients #2, #6, #13, and #17. They stated personal items were removed as patients' belongings could contain items such as medications, weapons, or items with strings, and their clothing was also removed to ensure patients did not elope from the facility before they were treated. RN #1 stated patients were at risk of death by self-strangulation if they were allowed access to personal belongings with strings.

RN #1 stated patients with psychiatric complaints were placed in a room close to the nurses' station. They stated family was an acceptable choice for monitoring patients with psychiatric complaints if staff felt the family would not cause the patient to escalate in harmful behaviors. RN #1 stated although there was a risk patients could physically harm their families, due to a lack of staff sitters, family members were needed to assist with monitoring. In contrast to the review of medical records and observations made in the ED, which did not reveal continuous staff monitoring but did reveal ligature risks in the patient rooms and restroom, RN #1 stated safety was an important consideration when monitoring psychiatric patients.

ii. On 5/1/24 at 8:55 a.m., an interview was conducted with Manager #2. Manager #2 stated there was no facility policy on sitters for patients with psychiatric complaints. They stated patients were placed in a room close to the nursing station and observed by the nurses. Manager #2 stated for children with psychiatric needs, the facility expected the parents to be at the bedside to inform staff if the children escalated. Manager #2 stated staff would not continuously monitor or observe these patients as this was the parents' role, as revealed in the record review for Patients #2 and #6. Manager #2 stated as the expectation and goal was that the family would monitor the patients, the nursing notes would not document the monitoring or observation. Manager #2 stated having parents monitor pediatric patients was important as the children were distressed, potentially impulsive, in a strange environment, and needed the constant presence of family. However, Manager #2 stated there was a risk patients with psychiatric complaints would revert to erratic behavior, would elope, or harm themselves or others if they were not closely monitored by staff.

Manager #2 stated staff accompanied patients with psychiatric complaints to the restroom, although the staff then waited outside the closed door. They stated the room was not cleared before patient use, the call light remained in the bathroom, and the patients were not monitored inside. This statement along with observations of the restroom, revealed patients were allowed unmonitored access to items which they could use for harm to self or others. Manager #2 also stated Patient #17, after being placed on the M1 hold, was accompanied to the cafeteria to allow them to select their own food, and staff did not believe this put the patient at additional risk of self-harm.

Manager #2 stated there was no standard procedure for patients admitted to the ED for suicidal ideation. They stated it would be helpful however, to have a standard procedure for patients screened as high risk on the C-SSRS to ensure consistent application of suicide precautions. Manager #2 stated currently, patient belongings were not removed and patient rooms were not cleared unless it was deemed necessary, and was only done on a case-by-case basis. They stated for patients on an M1 hold however, belongings were removed, patients were given gowns, and rooms were cleared.

This was in contrast to a review of medical records for Patients #6, #13, and #17 which did not reveal this was done. Manager #2 stated Patient #13 must not have arrived with belongings apart from their clothing, although they stated there was no way to know given the medical record did not reveal the removal of any belongings. Manager #2 stated there was a risk patients could have used any personal belongings or items left in the patient room or restroom to cause harm, especially if the patients were at risk for self-harm by strangulation.

iii. On 5/1/24 at 2:23 p.m., an interview was conducted with ED physician (Physician) #3. Physician #3 stated for patients with psychiatric needs, it was important to make sure their room was made safe and to monitor the patient if there was a concern they wanted to harm themselves and had a plan to do so. This statement was in contrast to a review of the medical records for Patients #2, #6, #13, and #17, which did not reveal evidence patient rooms were made safe or the patients were continuously monitored. Physician #3 stated ideally, there would be a safe room for psychiatric patients which would not allow patient access to anything in which they could harm themselves. Physician #3 stated if a patient was on a mental health hold, their belongings were to be removed to ensure everyone's safety, which was in contrast to a review of the medical records for Patients #6, #13 and #17. Physician #3 stated for pediatric patients with psychiatric complaints, they preferred for the parents to monitor the patient. They stated they assessed the situation, patient, and their family, and if Physician #3 felt the family was not a safe option due to safety concerns such as abuse, someone else, including a friend, could monitor the patient. Physician #3 stated sometimes their assessment of the family or friend was wrong and they did need to "backtrack" with who was allowed to monitor the patient. These statements were in contrast to the Nursing Standards of Patient Care policy which read, each patient was provided safety measures and nursing care designed to reduce the risk of intervention and reduce risk in the care environment. Physician #3 then stated patient monitoring was important to prevent patients from leaving the facility or self-harming, including hanging themselves, obtaining weapons with which to harm themselves, or using their own belongings to harm themselves.