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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure a safe environment by not removing all potential sharps from the immediate area of a patient with suicidal thoughts and the facility failed to ensure one to one direct visual observation was maintained on a patient with suicidal thoughts.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP4 and EMP9) regarding the survey team's concerns related to Patient Rights on October 26, 2022, at approximately 1300.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, observation, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a safe environment by not removing all potential sharps from the immediate area of a patient with suicidal thoughts and ideations for one of one applicable medical record reviewed (MR1) and the facility failed to ensure one to one direct visual observation was maintained on a patient with suicidal thoughts for one of one applicable medical record reviewed (MR2).

Findings include:

Review on October 26, 2022, of the facility's "Patient rights & responsibilities" brochure, no review date, revealed "...Care delivery ... Receive kind, respectful, safe, quality care delivered by skilled staff ..."

Review on October 26, 2022, of facility policy, "Suicide/Self Harm Precautions," approved April 21, 2022, revealed "Purpose To provide guidelines for staff caring for patients when there is a reasonable risk the patient may endanger themselves and/or others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm. Persons Affected All hospital personnel ... Definitions ... 1:1 Direct Visual Observation: The provision of a member of the hospital's staff to be in constant attendance and in close proximity to the patient, even during bathroom use (patient will be accompanied by appropriate clinical staff). The staff member must have a clear and unobstructed view of the patient at all times. ... Upon completion of the suicide evaluation indicating ideation with intent (high risk): 1. The 1:1 direct visual observation will be provided to observe the patient throughout the hospital stay or until the patient is medically cleared, admitted/transferred to a Psychiatric unit, or an evaluation by a provider and an order is placed to discontinue the 1:1. a. GWV- 1:1 cannot be discontinued without psychiatric evaluation ... 2. The 1:1 direct visual observation will be provided by personnel from the healthcare team, which may consist of: nursing personnel, ED technician, companion, and/or Security. The personnel will be determined based on the assessment of the patient. ..."

1. Review of MR1 on October 26, 2022, revealed this patient was admitted to the Emergency Department (ED) on October 23, 2022, at 1800, with complaint of suicidal thoughts and ideations; was hearing voices and having hallucinations. The facility placed MR1 in hallway bed 19 and assigned this patient a one-to-one sitter at the bedside at 1816.

Interview with EMP1 and EMP4 on October 26, 2022, at approximately 0950 confirmed MR1 was admitted to the ED on October 23, 2022, at 1800, with complaint of suicidal thoughts and ideations; was hearing voices and having hallucinations; the facility placed MR1 in hallway bed 19 and this patient was assigned a one-to-one sitter at the bedside at 1816.

Review of MR1 on October 26, 2022, revealed documentation dated October 23, 2022, indicating EMP7 approached MR1 at 1846 to perform blood collection; MR1 lunged toward the phlebotomy (blood draw cart) grabbed the pen that was on the top of the cart and began stabbing self in the right side of the neck resulting in a penetrating traumatic one - inch stab wound; nursing staff applied pressure to the right side of the neck due to suspected venous bleeding.

Interview with EMP1 and EMP4 on October 26, 2022, at approximately 1100 confirmed the documentation in MR1 dated October 23, 2022, indicating EMP7 approached MR1 at 1846 to perform blood collection; MR1 lunged toward the phlebotomy (blood draw cart) grabbed the pen that was on the top of the cart and began stabbing self in the right side of the neck resulting in a penetrating traumatic one - inch stab wound; nursing staff applied pressure to the right side of the neck due to suspected venous bleeding.

Review of MR1 on October 26, 2022, revealed physician documentation dated October 23, 2022, indicating MR1 was moved from hallway bed 19 and taken to the trauma area of the ED where MR1 was immediately intubated (a breathing tube inserted into the mouth then down the airway to assist the patient to breath).

Interview with EMP1 and EMP4 on October 26, 2022, at approximately 1110 confirmed the documentation in MR1 dated October 23, 2022, indicating MR1 was moved from hallway bed 19 and taken to the trauma area of the ED where MR1 was immediately intubated (a breathing tube inserted into the mouth then down the airway to assist the patient to breath).

Review of MR1 on October 26, 2022, revealed physician documentation dated October 23, 2022, at 2003 indicating the facility performed a bronchoscopy (a lighted fiberoptic scope used to examine the airway) to determine tracheal injury.

Interview with EMP1 and EMP4 on October 26, 2022, at approximately 1110 confirmed the physician documentation in MR1 dated October 23, 2022, at 2003 indicating the facility performed a bronchoscopy to determine tracheal injury.

Review of MR1 on October 26, 2022, revealed physician documentation dated October 24, 2022, at 0758 indicating the facility performed an upper endoscopy (a lighted flexible scope used to examine the digestive system) to evaluate for suspected esophageal perforation.

Interview with EMP1 and EMP4 on October 26, 2022, at approximately 1115 confirmed the physician documentation in MR1 dated October 24, 2022, at 0758 indicating the facility performed an upper endoscopy to evaluate for suspected esophageal perforation.

2. Observation tour of the Emergency Department (ED) completed on October 26, 2022, at 0955 revealed EMP6 was assigned to MR2 as a 1:1 suicide sitter. EMP6 was observed to have a book open on top of the 1:1 suicide sitter documentation board.

Interview on October 26, 2022, with EMP4 and EMP5 confirmed EMP6 was assigned to MR2 as a 1:1 suicide sitter and confirmed EMP6 had a book open on top of the 1:1 suicide sitter documentation board. EMP4 and EMP5 confirmed employees are not to have books open on the 1:1 documentation board while assigned to a 1:1 suicide watch.

Review on October 26, 2022, of the facility " One to One Sitter Training One to One Sitter Responsibilities and Training Suicide Precautions, " no date provided, revealed " ... 1:1 Observer Expectations Continuous, unobstructed view of the patient. ...1:1 observer should not bring any items into the patient room that distracts from continuous 1:1 visual observation, for example: ...Book/reading material ... "

Interview on October 26, 2022, with EMP4 and EMP5 confirmed the facility's One to One Sitter Training One to One Sitter Responsibilities and Training Suicide Precautions indicating the 1:1 Observer Expectations Continuous, unobstructed view of the patient and the 1:1 observer should not bring any items into the patient room that distracts from continuous 1:1 visual observation, for example a book or reading material.

Cross reference
482.13 Patient Rights