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Based on observation, interview, document and medical record review, it was determined the governing body failed to ensure that the facility was in compliance with all applicable conditions of participation (CoP). Specifically:

(a) the Condition of Patient Rights is not met for failure to maintain patients' safety by ensuring that the plan of correction from a previous survey regarding implementation of risk mitigation strategies for patients who are not deemed to be at an acute risk for suicide were fully implemented;

(b) the Condition of Physical Environment is not met for failure to ensure and maintain the condition of the physical plant and overall hospital environment in such a manner that the safety and well-being of the patients are assured;

(c) the Condition of Quality Assessment and Performance Improvement is not met for failure to develop quality indicators to measure, analyze and track patient safety issues, and implement a plan for improvement, and (d) use the data collected from the incident reports to identify problem areas and implement changes.

As a result, patients were placed at risk for harm.

Findings include:

(a) In response to a survey conducted on 3/21/16 where looping hazards were identified, the hospital submitted a plan for risk mitigation strategies. This plan addressed correcting physical environment hazards and increasing monitoring of patients based on needs identified as part of their risk assessment. On 9/18/16, Patient #1 was admitted to Unit 5 North for suicidal ideation, which is a designated unit for patients with self-injurious behavior. The psychiatrist ' s plan included monitoring the patient's suicidality and frequent checks at 15 minutes intervals was ordered by the physician. On 9/22/16 at 7:55 AM, Patient #1 was found hanging in the bathroom in Room 230 on Unit 5 North, and he expired at 9:06 AM, despite resuscitative measures. Review of the medical record for Patient #1 identified that the staff member assigned, failed to perform monitoring observations as per facility policy and a visual monitoring check of the patient was not conducted. (Refer to Tag A 144).


(b) On 9/22/16 at 7:55 AM, Patient #1 was found in the bathroom in Room 230 on Unit 5 North with a noose around his neck, which was connected to the window apparatus. He was later pronounced dead at a nearby hospital. Inspection of this bathroom on 11/8/16, revealed looping hazards at the bathroom window, ventilation system, toilet and door handles.

During a tour of the facility on 11/8/16 between 10:00 AM and 2:30 PM, the surveyor identified looping hazards on units 3 North, 4 North, 5 North, 6 North, 2 South, 5 South and 6 South. (Refer to Tag A 701).


c) Review of the hospital ' s Quality Performance Improvement Minutes for 4/18/16 to 9/19/16 showed no evidence that the hospital discussed or reviewed suicide attempts, patient grievances/complaints, and incidents. Examples include:

The hospital had 14 patients attempted suicides from 3/20/16 to 11/30/16, five (5) in the past three (3) months.
The hospital had more than 130 patient grievance/complaints from January 2016 to November 2016.
The hospital had more than 180 pages of patient incidents from January 2016 to November 2016.

There was no documented evidence that the above data was reviewed, trended, and analyzed to identify patterns and develop a plan for improvement (Refer to Tag A 273 and Tag A 283)

During interview on 12/2/16 at 12:35 PM, Staff C, Director, Quality, and Patient Services acknowledged incidents/adverse occurrences, and patient grievances/complaints were not discussed or analyzed in the quality improvement meetings. Staff C stated, " We only look at the ones where the standards are not met. " There was no evidence that these reviews were discussed in the performance meetings.

During interview on 12/2/16 at 3:05 PM, Staff D, Medical Director acknowledged that the hospital does not track, trend and analyze all patient incidents each month. Staff D stated, " Just the OMH reportable were reviewed. "

Based on interview, medical record and document review, it was determined the facility failed to conduct patient checks that included visual observation of the patient every 15 minutes, to ensure patient safety. This failure resulted in the death of a patient and placed all patients at risk for harm. (Patient #1).


Findings include:

Review of medical record for Patient #1 revealed, the patient was admitted to the facility on 9/18/16 for suicidal ideation and was subsequently transferred to Unit 5 North. The psychiatrist's plan included monitoring the patient's suicidality and frequent checks at 15 minute intervals was ordered by the physician. On 9/22/16 at 7:55 AM, Patient #1 was found hanging in the bathroom in Room 230, and expired at 9:06 AM that morning despite resuscitative measures.

Review of the Observation Checklist Form revealed Staff B, a Mental Health Worker who was assigned to conduct frequent checks, performed 15 minutes rounding and checks on 9/22/16 at 7:15 AM, 7:30 AM and 7:45 AM. Staff B documented that the patient was in the bathroom on each occasion and there was no documentation to confirm a visual check of the patient.

The policy titled, "Documentation Guidelines - Observation Checklist," last revised 1/2015, states: "the staff member performing observations is responsible to confirm the presence of respirations; and for patient's on status that the patient's face, neck and hands are visible."

During interview on 11/28/16 at approximately 12:30 PM, Staff C, Director Quality and Patient Services stated that Staff B did not perform a visual check when the 15 minute checks were done.

Refer to Tag A 144.

Based on observation, interview, medical record and document review in one (1) of 30 medical records reviewed, it was determined the facility did not implement its policy and procedure to ensure that patients received care in a safe setting (Patient #1).

Findings include:

Review of medical record for Patient #1 revealed the patient was admitted to the facility on 9/18/16 for suicidal ideation. The psychiatrist's plan included monitoring his suicidality and an order for frequent checks at 15 minute intervals was documented by the psychiatrist on 9/18/16 at 6:32 PM. Patient was subsequently transferred to Unit 5 North which is designated for patients with self-injurious behavior. On 9/22/16 at 7:55 AM, Patient #1 was found hanging in the bathroom in Room 230, and he expired at 9:06 AM that morning despite resuscitative measures that were implemented when he was found.

Review of the Observation Checklist Form revealed Staff B, a Mental Health Worker who was assigned to conduct frequent checks, performed 15 minutes rounding and checks on 9/22/16 at 7:15 AM, 7:30 AM and 7:45 AM. Staff B documented that the patient was in the bathroom on each occasion and there was no documentation to confirm a visual check of the patient.

The policy titled, "Documentation Guidelines - Observation Checklist," last revised 1/2015, states: "the staff member performing observations is responsible to confirm the presence of respirations; and for patient's on status that the patient's face, neck and hands are visible."

Staff C, Director, Quality and Patient Services stated on 11/28/16 at approximately 12:30 PM that Staff B did not perform a visual check when the 15 minute checks were done.


Inspection of this bathroom on Unit 5 North on 11/28/16 at 11:25 AM, revealed there were looping hazards at the bathroom window, ventilation system, toilet, and door handles.

These findings were confirmed by Staff A, Director of Facilities Operation, on 11/28/16 at approximately 11:45 AM.

Based on document review and interview, it was determined that the hospital failed to;
(a) develop quality indicators to measure, analyze and track patient safety issues, and implement a plan for improvement, and (b) use the data collected from the incident reports to identify problem areas and implement changes.

This failure placed patients at risk for harm.



Findings include:
Review of the hospitals' Quality Performance Improvement Minutes for 4/18/16 to 9/19/16 showed no evidence that the hospital discussed or reviewed suicide attempts, patient grievances/complaints, and incidents. Examples include:

The hospital had 14 patients attempted suicides from 3/20/16 to 11/30/16, five (5) in the past three (3) months.
The hospital had more than 130 patient grievance/complaints from January 2016 to November 2016.
The hospital had more than 180 pages of patient incidents from January 2016 to November 2016.

There was no documented evidence that the above data was reviewed, trended and analyzed to identify patterns and develop a plan for improvement. (Refer to Tag A 273 and Tag A 283).



During interview on 12/2/16 at 12:35 PM, Staff C, Director, Quality and Patient Services acknowledged incidents/adverse occurrences, and patient grievances/complaints were not discussed or analyzed in the quality improvement meetings. Staff C stated, "we only look at the ones where the standards are not met." There was no evidence that these reviews were discussed in the performance meetings.

During interview on 12/2/16 at 3:05 PM, Staff D, Medical Director acknowledged that the hospital does not track, trend and analyze all patient incidents each month. Staff D stated "just the OMH reportable were reviewed."

Based on document review and interview, a) the hospital did not develop quality indicators to measure, analyze, track patient safety issues, and b) implement plans for improvement.


Findings include:

a) The Hospital's Policy and Procedure Titled "Quality and Patient Safety Plan," states the facility would "Review and investigate any adverse patient events, including near misses, death, complaints." They would, "Develop procedures for immediate review, investigation and response to serious patient safety issues."


Review of the hospital Quality Performance Improvement Minutes for 4/18/16 - 9/19/16 showed:

1. Suicide attempts. The hospital had 14 patients that attempted suicides from 3/20/16 to 11/30/2016, 5 of these occured in the last 3 months.

2. Patient grievances/complaints. The hospital had more than 130 patient grievances and complaints from January 2016 to November 2016.

3. Incidents. The hospital had more than 180 pages of patient incidents from January 2016 to November 2016.

4. Hospital transfers. There was no documented evidence on the number of patients that were transferred to hospital.

5. Mortality. The hospital's record showed 6 patient deaths within 30 days of discharge.

There was no documented evidence that the hospital analyzed and tracked these issues to determine impact on patient care.

During interview on 12/2/16 at 12:35 PM, Staff C, Director, Quality and Patient Services, acknowledged that the Quality Improvement Minutes had no information regarding the above issues.

During interview on 12/2/16 at 3:05 PM, Staff D, Medical Director, stated that he did not attend most of the Quality Improvement meetings, as a result he was not aware of some of the above issues.


b) In response to a survey conducted on 3/21/16 where looping hazards were identified, the facility submitted a plan for risk mitigation strategy regarding the physical environment hazards. There was no documented evidence that the plan was fully implemented. (Refer to Tag A 144).


On 12/1/16, the hospital provided a list to the Surveyor indicating that from 3/2016 to 11/2016, 10 patients had attempted suicide.
Review of the hospital's incident reports, identified that the hospital had 4 more suicide attempts than reported (Total of 14). In 3 of these suicide attempts the patient used a looping device.

Based on document review and interview, the hospital did not ensure that the performance improvement program used the data collected from the incident reports to identify problem areas and implement changes.


Finding include:

Review of the hospital Performance Improvement Minutes for 4/18/16 - 9/19/16 showed the hospital had more than 180 pages of patient's incidents since January 2016.

Review of the hospital's incident reports identified incidents showing patterns for contraband possession that was more prevalent on some units than others.

Example:
It was noted that on 5 North, patients had a significant amount of issues relating to possession of contraband. In some incidents, patients were using this contraband to inflict self injury. Some of this contraband was described as, sharpened rocks, bolts, nails, screws, staples, batteries and a 14 inch cloth that was brought from patient's home.

The Performance Improvement Minutes had no evidence that this information was reviewed, or assessed by the facility to identify problem areas and opportunities for change.


During interview on 12/2/16 at 12:35 PM, Staff C acknowledged that not all incidents were discussed or analyzed in the quality improvement meetings.

Based on observation and interview, it was determined the facility failed to maintain the physical condition of the patient care units to ensure the safety of all patients.

This failure placed all patients at risk for harm and contributed to the death of Patient #1.

Findings include:

Review of medical record for Patient #1 revealed the patient was admitted to the facility on 9/18/16 for suicidal ideation. The patient was transferred to Unit 5 North (Psychiatric unit) which is designated for patients with self-injurious behavior. On 9/22/16 at 7:15 AM, the patient was found with a noose around his neck tied to a window chain. The patient was pronounced dead on 9/22/16 at 9:06 AM.

During a tour of Unit 5 North on 11/8/16 between 10:00AM to 11:00AM, Windows in numerous patient rooms were operated by counterweights on exposed chains that permitted looping by Patient #1.

The inspection of other psychiatric units (3 North, 4 North, 5 North, 6 North, 2 South, 5 South, and 6 South) on 11/8/16 between 11:00 AM and 2:30 PM, revealed several fixtures in the units that were looping hazards, and were not the safety types approved by the Office of Mental Health (OMH) for use in psychiatric facilities (Refer to Tag A 701).

These findings were verified by the Patient Services Administrator and the Director of Facilities Operations at the time of observation.

Based on observation and interview, the facility failed to maintain the condition of the physical plant and overall hospital environment in such a manner that the safety and well-being of the patients are assured.


Findings include:

During a tour of the facility on 11/8/2016 between 10:00 AM and 2:30 PM it was observed that fixtures in unsupervised patient areas were not of an Office of Mental Health (OMH) approved type, and were not designed to prevent a ligature from being looped over them. Examples include (but are not limited to):

a. Patient restrooms on units 3 North, 4 North, 5 North, 6 North, 2 South, 5 South and 6 South were outfitted with sink and shower hardware that were conventional lever type fixtures.

b. Toilet and sink plumbing in patient restrooms were exposed rather than being boxed in.

c. Fixtures such as toilet paper holders and soap dishes were of the conventional type and protruded from the rest room walls.

d. Doors in patient bedrooms and seclusion rooms throughout these units had standard door hinges rather than solid piano style hinges.

e. Door handles in patient bedrooms and seclusion rooms were conventional turn style knobs rather than OMH approved cone shaped door handles.

f. Ceilings in numerous patient bedrooms and seclusion rooms on the above listed units consisted of acoustic tiles set into a grid, rather than a monolithic ceiling.

g. Overhead sprinklers in patient bedrooms and seclusion rooms are not designed to break away if a weight greater than 50 pounds is suspended from them.

h. Radiators in patient bedrooms and restrooms had slat style vents big enough to loop a ligature through.

i. Windows in numerous patient rooms were operated by counterweights on exposed chains.

Failure to install and maintain fixtures throughout the facility that prevent ligatures from being looped over them may result in severe injury or patient death.

These findings were verified by the Patient Services Administrator and the Director of Facilities Operations at the time of observation.

These findings were verified by the Patient Services Administrator and the Director of Facilities Operations at the time of observation.