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Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that suicidal patients were monitored and safe from ligature risks. This potentially places all current and future suicidal patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that a suicidal patient was not able to commit suicide (A-144 A).

2. The Hospital failed to ensure that psychiatric patients' rooms were free from ligature risks to prevent harm to patients. (A-144 B).

3. The Hospital failed to document that a contraband search was completed for suicidal patients and the rooms they occupied (A-144 C).

4. The Hospital failed to ensure that each suicidal patient was on 1:1 monitoring by a staff member trained in suicide precautions and seclusion (A-144 D).



An Immediate Jeopardy (IJ) began on 6/19/19 (date of Pt. #1's suicide attempt), for the Hospital's failure to monitor Pt. #1, failure to remove ligature risks, and failure to ensure staff education/training regarding suicide precautions and seclusion. Pt #1's death followed. This failure potentially placed all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 7/1/19 at 1:00 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Associate Vice President of Nursing, and Regional Vice President of Quality. The Hospital failed to implement and evaluate corrective measures. IJ was not removed by the Hospital by the survey exit date of 7/3/19.

Also, the Condition of Patient Rights was not met as evidenced by:

5) The Hospital failed to ensure that the least restrictive methods were tried prior to using seclusion (A - 144 E).




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A. Based on document review and interview, it was determined that for 1 of 1 suicidal patient (Pt. #1) in the Emergency Department (ED), the Hospital failed to ensure that a suicidal patient was not able to commit suicide.

Findings include:

1. On 7/3/19 at 10:30 AM, the Hospital's policy titled, "Suicide Precautions." (revised 5/2019), was reviewed. The policy required, "Policy: Suicide precautions shall be provided for any patient expressing and/or exhibiting suicidal ideation or behavior... 5. With the initiation of suicide precautions, a 1 to 1 [one staff member with one patient] observation sitter will remain with the patient at all times within arms's length; in the emergency room, security officers will remain with the patient until a sitter is available and toileting needs will be handled by nursing personnel..."

2. On 7/1/19, Pt. #1's clinical record was reviewed. Pt. #1 was a 35 year old male, involuntarily transported to the ED by ambulance on 6/18/19, arriving at 10:49 PM, with diagnoses of intentional drug overdose and suicide ideation (SI). Pt. #1's ED History and Physical (completed by MD #1) dated 6/18/19 at 10:53 PM, included that Pt. #1 presented to the ED after ingesting "a handful of 0.5 mg [milligram] Ativan [medication to relieve anxiety], half a bottle of vodka, and a handful of 2 mg Klonopin [medication to treat anxiety] ... Patient states this is the first time he tried to end his life ..."

- An ED Physician's (MD #1) Progress Note dated 6/19/19 at 8:23 AM, included, (written more than 9 hours after the History and Physical was completed) "Patient with multi-drug overdose in a suicide attempt ... Patient is sleepy but easily aroused... Patient waiting to be seen by Social Worker..."

- A Nursing Note (E #7) dated 6/19/19 at 2:46 PM, included, "At 1:35 PM, Security Guard [E #5] checked on Patient in bathroom because Patient was quiet. He called me to bathroom. Found Patient lying on floor with a red bag over his head. Immediately removed bag, hearing sonorous [loud] breaths then apneic [no breath] and pulseless. Immediately started CPR [cardio pulmonary resuscitation] ... Prior to incident Patient was calm and cooperative. He was eating and drinking coffee. Patient aware he was going to be transferred to another Hospital."

- A nursing flowsheet dated 6/19/19 at 1:15 PM, documented tht Pt #1's behavior was "cooperative, poor judgement, sad."

- Pt #1's Consultation Report dated 6/19/19 at 3:28 PM, included, "...The patient...he was found in a restroom in the ED... with a plastic bag around his head unresponsive and pulseless. CPR [cardiopulmonary resuscitation] was performed with return of spontaneous circulation...Patient is admitted to ICU [Intensive Care Unit]...He is exhibiting spontaneous myoclonus [sudden, involuntary muscle jerk, shake, or spasm] and coma [unconsciousness]... His CT [computerd tomography scan] [of the head]...demonstrates effacement [elimination] of the cortical sulci [groves in the brain] consistent with diffuse [spread over a wide area] cerebral edema [brain swelling]."

3. On 7/1/19 at 1:55 PM, an interview was conducted with the Security Guard (E #5) who was monitoring Pt. #1 on 6/19/19. E #5 stated that Pt. #1 went to the ED washroom at approximately 1:20 PM, and closed the door while E #5 remained outside, without visual contact. At approximately 1:30 PM, E #5 heard the toilet flush, but at approximately 1:35 PM, after not hearing anything, E #5 called to Pt. #1. E #5 stated that Pt. #1 did not answer and E #5 announced to Pt. #1 that he was going to enter, and opened the washroom door. Pt. #1 was lying on the floor. E #5 called the Nurse (E #7) who responded at approximately 1:35 PM.

4. On 7/2/19 at 3:05 PM, an interview was conducted with E #7, Pt. #1's ED Nurse. E #7 stated that she heard E #5 "banging on the bathroom door" and saying, "I'm coming in.". E #5 called E #7 to the bathroom and E #7 saw a plastic bag on Pt. #1's head, removed it and started CPR. E #7 stated that the Security Guard was supposed to call the Nurse when a suicidal patient needs to use the washroom. E #5 did not inform E #7 that Pt. #1 needed to use the washroom. Clinical staff are supposed to stay with suicidal patients who are in the washroom.

5. A progress note (Intensive Care Physician) on 6/22/19, included, "Patient pronounced dead at 4:36 PM and placed back on ventilator [for the Gift of Hope organ procurement organization]."



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B . Based on document review, observation, and interview, it was determined that for 2 of 2 units (ED & Behavioral Health Unit (5 West), the Hospital failed to ensure that psychiatric patients' rooms and bathrooms were free from ligature risks. This has the potential to affect the safety of the 10 current psychiatric patients and any future psychiatric patients who become suicidal.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 7/1/19, 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. The Hospital's policy titled, "Suicide Precautions" (approved 5/2019 ), was reviewed on 7/1/19. The policy required, "...Supplies and linens should be limited to what is needed for care and extras not left in the room (suction supplies, oxygen tubing, cords...)"

3. The Hospital's Behavioral Health Risk Assessment (dated 1/14/19), was reviewed on 7/1/19, and indicated that the Hospital identified the ligature risks present in the following areas:

- Cords - Risk Score 10 (Risk level 8-14 is high)

- Interior Bathroom Doors -Risk Score 12 (Risk level 8-14 is high)

- Bathroom Call Buttons - Risk Score 8 (Risk level 8-14 is high)

4. On 7/1/19 at 10:00 AM, an observational tour was conducted on Behavioral Health Unit (5 West). There were 14 semi-private (2 beds in each room) patient rooms on 5 West. There were 10 patients on the census. There were no patients on suicide precautions. Ligature risks were identified as follows:

- Each patient room entry door was composed of solid wood that met flat against the solid metal frame, creating a ligature risk at the top when the door was closed. Entry room doors were open when the patients were in the room. Entry room doors were closed and locked when the patients were not in the room.

- Patient rooms (540, 542, 544, 545, 546, 547, 548, 549, 550, 551, 552 & 554) had an unlocked solid wooden bathroom door (reaching the full length of the frame) meeting a solid frame and had a pull cord in each room (approximately 2 feet long) in the bathroom.

-Each patient room had medical beds with power cords (approximately 8 feet long) which could be used for hanging by the patients on the unit.

- Rooms 541, 544, 545-2, 547-2 & 551 had call light cords that were approximately 10 feet long, which could be used for hanging by the patients on the unit.

-Room 544 had 2 oxygen flow meters (flow control valve to regulate the flow of oxygen) attached to the wall which could be used for hanging by the patients on the unit.

-Room 545-2 had a respiratory machine with plastic tubing approximately 3 feet in length, which could be used for hanging by the patients on the unit.

5. On 7/1/19 at 1:30 PM, a tour was conducted in the Emergency Department (ED). There was 1 patient (Pt #2) with Suicidal Ideation (SI). Pt #2 was admitted to the ED on 7/1/19 at 1:51 AM with suicidal ideation and was observed to have 1:1 monitoring. Pt #2 was in ED room #19. Room #19 had a moveable bedside table and chair, an oxygen flowmeter and EKG (electrocardiogram/heart) monitor tubing contained by plastic ties. There was no commode in Room #19.

6. On 7/1/19 at 2:00 PM, an interview was conducted with the ED supervisor (E #3). E #3 stated that if Pt #2 needs to go to the bathroom, staff will bring in a commode or Pt #2 can use the restroom. E #3 opened the restroom door and the following ligature risks were identified: 1) call light cord 2) rails in the shower area that could be used for hanging. E #3 stated that the 1:1 staff member keeps her foot in the door of the bathroom while the patient uses the bathroom.

7. On 7/1/19 at approximately 11:00 AM, an interview was conducted with the Director of the Behavioral Health Unit (E #4). E#4 stated that the Hospital is working toward eliminating call light cords. E #4 stated that the Hospital is trying to have the call light system incorporated into the bed so that a patient can touch a button on the siderail instead of using the cord.

C. Based on document review and interview, it was determined that for 7 of 10 Emergency Room Patients (Pt #2, Pt #3, Pt #4, Pt #5, Pt #6, Pt #8, & Pt #10) on Suicide Precautions, the Hospital failed to document a contraband search of the patient and the physical environment of the psychiatric patient while in the ED.

Findings include:

1. On 7/2/19, the Hospital's policy titled, "Contraband" (effective 1/14/2019) was reviewed. The policy indicated "...The known or suspected use of contraband or unauthorized medications by persons on the Hospital property shall be immediately reported to the Security Department..."

2. On 7/2/19, the Hospital's policy titled, "Management of the Behavioral Health Patient in the Emergency Department" (revised 8/2018) was reviewed. The policy indicated "...Belongings will be removed from the treatment room and searched by an ED (Emergency Department) staff member and/or Security for any contraband (i.e. medication, sharp objects, alcohol, etc.)..."

3. On 7/2/19, Pt #2's clinical record was reviewed. Pt #2 was a 31 year old female admitted to the ED on 7/1/19 with the diagnosis of psychiatric evaluation. Pt #2's physician orders dated 7/2/19 noted that Pt #2 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

4. On 7/2/19, Pt #3's clinical record was reviewed. Pt #3 was 26 year old male admitted to the ED on 6/27/19 with the diagnosis of psychiatric evaluation. Pt #3's physician orders dated 6/27/19 noted that Pt #3 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

5. On 7/2/19, Pt #4's clinical record was reviewed. Pt #4 was a 13 year old female admitted to the ED on 6/28/19 with the diagnosis of depression. Pt #4's physician orders dated 6/28/19 noted that Pt #4 was on Suicide Precautions. The clinical record lacked documentation of a contraband search.

6. On 7/2/19, Pt #5's clinical record was reviewed. Pt #5 was a 53 year old male admitted to the ED on 6/28/19 with the diagnosis of ETOH/HI (alcohol/homicidal ideation - thought to kill others). Pt #5's physician orders dated 6/28/19 noted that Pt #5 was on Suicide Precautions. The clinical record lacked documentation of a contraband search.

7. On 7/2/19, Pt #6's clinical record was reviewed. Pt #6 was a 28 year old male admitted to the ED on 6/29/19 with the diagnosis of psychiatric evaluation. Pt #6's physician orders dated 6/29/19 noted that Pt #6 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

8. On 7/2/19, Pt #8's clinical record was reviewed. Pt #8 was a 38 year old female admitted to the ED on 6/30/19 with the diagnosis of anxiety. Pt #8's physician orders dated 6/30/19 noted that Pt #8 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

9. On 7/2/19, Pt #9's clinical record was reviewed. Pt #9 was an 83 year old female admitted to the ED on 6/30/19 with the diagnosis of anxiety. Pt #9's physician orders dated 6/30/19 noted that Pt #9 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

10. On 7/2/19, Pt #10's clinical record was reviewed. Pt #10 was a 14 year old male admitted to the ED on 6/26/19 with the diagnosis of psychiatric evaluation. Pt #10's physician orders dated 6/26/19 noted that Pt #10 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of a contraband search.

11. On 7/2/19 at approximately 2:30 PM, an interview was conducted with the Emergency Room Registered Nurse (E #7). E #7 stated that contraband searches are done for patients in the Emergency Room but the contraband searches were not documented in the clinical record.



D. Based on document review and interview, it was determined that for 10 of 10 Emergency Room Patients (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6, Pt #7, Pt #8, Pt #9 & Pt #10) on Suicide Precautions, the Hospital failed to ensure that each patient was on 1:1 monitoring by a staff member trained in suicide precautions/ seclusion.

1. On 7/2/19, the Hospital's policy titled, "Restraint-Physical Hold-Seclusion" (revised 6/2019) was reviewed. The policy indicated "...Seclusion: The involuntary confinment of a person in a locked/unlocked room or area where the person is physically prevented from leaving...Trained staff continuously monitors each patient when in restraint, physical hold, and seclusion to maintain patient safety and ensure that airway and breathing are maintained..."

2. On 7/2/19, Pt #1's clinical record was reviewed. Pt. #1 was a 35 year old male, admitted to the ED on 6/18/19, with the diagnoses of intential drug overdose and suicide ideation. Pt #1 physician order dated 6/18/19 noted Suicide Precautions/seclusion. A Nursing Note dated 6/19/19 at 2:46 PM, included, "At 1:35 PM, Security Guard [E #5] checked on Patient in bathroom because Patient was quiet. He called me to bathroom. Found Patient lying on floor with a red bag over his head. Immediately removed bag, hearing sonorous [loud] breaths then apneic [no breath] and pulseless..."

3. On 7/2/19, Pt #2's clinical record was reviewed. Pt #2 was a 31 year old female admitted to the ED on 7/1/19 with the diagnosis of psychiatric evaluation. Pt #2's physician orders dated 7/2/19 noted that Pt #2 was on Suicide Precautions/ Seclusion. Pt #2's "Patient Observation Request" dated 7/1/19 noted that security officers were monitoring Pt #2 from 2:00 AM until a sitter arrived at 7:10 AM on 7/1/19.

4. On 7/2/19, Pt #3's clinical record was reviewed. Pt #3 was 26 year old male admitted to the ED on 6/27/19 with the diagnosis of psychiatric evaluation. Pt #3's physician orders dated 6/27/19 noted that Pt #3 was on Suicide Precautions/ Seclusion. Pt #3's "Patient Observation Request" dated 6/27/19 noted that security officers were monitoring Pt #3 from 4:15 AM until 3:20 PM on 6/27/19 until a sitter arrived.

5. On 7/2/19, Pt #4's clinical record was reviewed. Pt #4 was a 13 year old female admitted to the ED on 6/28/19 with the diagnosis of depression. Pt #4's physician orders dated 6/28/19 noted that Pt #4 was on Suicide Precautions. Pt #4's "Patient Observation Request" dated 6/28/19 noted that security officers were monitoring Pt #4 from 12:50 AM to 3:15 AM on 6/29/19 until Pt #4 was transferred to another Hospital.

6. On 7/2/19, Pt #5's clinical record was reviewed. Pt #5 was a 53 year old male admitted to the ED on 6/28/19 with the diagnosis of ETOH/HI (alcohol/homicidal ideation - thoughts of killing others). Pt #5's physician orders dated 6/28/19 noted that Pt #5 was on Suicide Precautions. Pt #5's "Patient Observation Request" dated 6/28/19 noted that security officers were monitoring Pt #5 from 5:10 PM unit 9:10 PM on 6/28/19 until a "sitter took over."

7. On 7/2/19, Pt #6's clinical record was reviewed. Pt #6 was a 28 year old male admitted to the ED on 6/29/19 with the diagnosis of psychiatric evaluation. Pt #6's physician orders dated 6/29/19 noted that Pt #6 was on Suicide Precautions/ Seclusion. Pt #6's "Patient Observation Request" dated 6/29/19 noted that security officers were monitoring Pt #6 on 6/29/19 from 4:10 PM to 7:15 PM, until a "sitter took over at 7:15 PM."

8. On 7/2/19, Pt #7's clinical record was reviewed. Pt #7 was a 20 year old female admitted to the ED on 6/26/19 with the diagnosis of depression (suicidal ideation). Pt #7's physician order dated 6/26/19 indicated "Seclusion." Pt #7's "Patient Observation Request" dated 6/26/19 noted that security officers were monitoring Pt #7 from 9:45 PM on 6/26/19 until 5:00 AM on 6/27/19 - "no sitters available for 1 to 1 watch..."

9. On 7/2/19, Pt #8's clinical record was reviewed. Pt #8 was a 38 year old female admitted to the ED on 6/30/19 with the diagnosis of anxiety. Pt #8's physician orders dated 6/30/19 noted that Pt #8 was on Suicide Precautions/Seclusion. Pt #8's "Patient Observation Request" dated 6/30/19 noted that security officers were monitoring Pt #8 from 5:30 PM until 6:35 PM, until a sitter arrived.

10. On 7/2/19, Pt #9's clinical record was reviewed. Pt #9 was an 83 year old female admitted to the ED on 6/30/19 with the diagnosis of anxiety. Pt #9's physician orders dated 6/30/19 noted that Pt #9 was on Suicide Precautions/ Seclusion. Pt #9's "Patient Observation Request" dated 6/30/19 noted that security officers were monitoring Pt #9 from 11:50 AM until 3:00 PM until sitter arrived.

11. On 7/2/19, Pt #10's clinical record was reviewed. Pt #10 was a 14 year old male admitted to the ED on 6/26/19 with the diagnosis of psychiatric evaluation. Pt #10's physician orders dated 6/26/19 noted that Pt #10 was on Suicide Precautions/ Seclusion. Pt. #10's "Patient Observation Request" dated 6/26/19 noted that security officers were monitoring Pt #10 from 11:15 PM on 6/26/19 until 6:15 AM on 6/27/19 -"no sitters available for 1 to 1 watch."

12. On 7/2/19 at approximately 2:45 PM, an interview was conducted with the Director of the Emergency Room (E #2). E #2 stated that the Security Officers stay with the suicidal patients for 1:1 monitoring until the sitter arrives.

13. On 7/2/19 at approximately 3:00 PM, an interview was conducted with the Vice President of Nursing (E #1). E #1 stated that security officers are not trained in seclusion. E #5's (Security Officer) personnel file was reviewed. There was no documentation of 1:1 monitoring training in E #5's personnel file.



E. Based on document review and interview, it was determined that for 6 of 10 Emergency Room Patients (Pt #1, Pt #2, Pt #6, Pt #7, Pt #9 & Pt #10), the Hospital failed to ensure a least restrictive method was used prior to seclusion.

Findings include:

1. On 7/2/19, the Hospital's policy titled, "Restraint- Physical Hold- Seclusion," (revised 6/2019) was reviwed. The policy required, "Philosphy... Our treatment approach promotes early intervention using non-violent, non-physical crisis prevention techniques to prvent, reduce, and eliminate restraint (R), physical hold (H), and seclusion (S)... R/H/S use are only implemented as a last resort when less restrictive interventions are ineffective..."

2. 2. On 7/2/19, Pt #1's clinical record was reviewed. Pt. #1 was a 35 year old male, admitted to the ED on 6/18/19, with the diagnoses of intentional drug overdose and suicide ideation. A physician's order dated 6/18/19 at 10:55 PM, required seclusion for 4 hours. The order was renewed 3 times (on 6/19/19 at 3:00 AM, 7:00 AM, and 11:00 AM). The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

3. On 7/2/19, Pt #2's clinical record was reviewed. Pt #2 was a 31 year old female admitted to the ED on 7/1/19 with the diagnosis of psychiatric evaluation. Pt #2's physician orders dated 7/2/19 noted that Pt #2 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

4. On 7/2/19, Pt #6's clinical record was reviewed. Pt #6 was a 28 year old male admitted to the ED on 6/29/19 with the diagnosis of psychiatric evaluation. Pt #6's physician orders dated 6/29/19 noted that Pt #6 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

5. On 7/2/19, Pt #7's clinical record was reviewed. Pt #7 was a 20 year old female admitted to the Ed on 6/26/19 with the diagnosis of depression (suicidal ideation). Pt #7's physician order dated 6/26/19 indicated "Seclusion." The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

6. On 7/2/19, Pt #9's clinical record was reviewed. Pt #9 was an 83 year old female admitted to the ED on 6/30/19 with the diagnosis of anxiety. Pt #9's physician orders dated 6/30/19 noted that Pt #9 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

7. On 7/2/19, Pt #10's clinical record was reviewed. Pt #10 was a 14 year old male admitted to the ED on 6/26/19 with the diagnosis of psychiatric evaluation. Pt #10's physician orders dated 6/26/19 noted that Pt #10 was on Suicide Precautions/ Seclusion. The clinical record lacked documentation of least restrictive methods that were tried prior to seclusion.

8. On 7/2/19 at approximately 2:45 PM, an interview was conducted with the Director of the Emergency Room (E #2). E #2 stated that least restrictive methods prior to seclusion should be documented in the patient's record.