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Based on Review of Policy and Procedure, Review of Clinical Record, Review of Video monitoring, and interview, it was determined the facility failed to provide care in a safe setting in that the facility did not provide a ligature free environment for two of two (#1 and #2) patients. The failed practices did not ensure the patients could not inflict harm upon themselves. The failed practice affected Patient #1 and #2 had the likelihood to affect all patients admitted to the facility. See A-0144 for details.

Based on Review of Policy and Procedure, Review of Clinical Record, Review of Video monitoring, and interview, it was determined the facility failed to provide care in a safe setting in that the facility did not provide a ligature free environment for two of two (#1 and #2) patients. The failed practices did not ensure the patients could not inflict harm upon themselves. The failed practice affected Patient #1 and #2 had the likelihood to affect all patients admitted to the facility. Findings follow.

A. Review of Policy and Procedure titled, "Patient Rights" revised 08/19/2015 showed the, "Patient had the right to receive care in a safe setting."

B. Review of Policy and Procedure titled, "Patient Observations," revised 04/10/2023, showed the following:
1. While on Line of Site (LOS) observation the patient must remain under constant observation including using the bathroom or bathing.
2. While on one-to-one observation the staff was to be within six feet and the patient was to be directly observed at all times.
3. When a patient was behind a closed door while in a restroom or bathing, staff may ask about patient status through the door and document on the "15-minute Observation Check Sheet."

C. Review of Policy and Procedure titled, "Inpatient Suicide Risk Assessment and Reassessment," revised 07/16/2021, showed, "If the reassessment indicates moderate or high positive risk, the physician must assess the patient and complete the Inpatient Suicide Risk Assessment and Evaluation and write a Progress Note within twenty-four hours."

D. Review Clinical records on 07/02/2024 at 10:30 AM, showed the following:
1. Patient #1's Clinical record dated 04/13/2024 at 11:59 PM and 06/30/2024 at 4:14 PM, showed while being monitored, the patient had wrapped personal clothing around their neck causing strangulation that resulted in transport to an acute care facility.
2. Patient #2's Clinical record dated 04/21/2024 at 5:40 PM, showed while being monitored during 15 minute shower time, the patient had wrapped personal clothing around their neck causing strangulation that resulted in transport to acute care facility. There was no evidence a physician conducted an Inpatient Suicide Risk Assessment or Reassessment.

E. Review of Video Monitoring on 07/02/2024 at 12:30 PM, showed the following:
1. Patient #1 video monitoring dated and 06/30/2024 at 4:14 PM, showed while being monitored, the patient had wrapped personal clothing around their neck causing strangulation that resulted in transport to acute care facility. In both occurrences the patient had covered their head with a suicide blanket which did not allow for visualization of head and neck.
2. Patient #2 video monitoring dated 04/21/2024 at 5:40 PM, showed while being monitored during scheduled 15 minute shower time, Patient #2 was not monitored for 41 minutes.

F. During an interview on 07/02/2024 at 11:15 AM, with the Chief Compliance Officer and Quality Manager, Surveyor #2 asked the following:
1. Describe your review process when there are events of the same or similar type which pose a high risk for patient harm and/or death. The Chief Compliance Officer stated, "That there is no trigger for aggregating events for further administrative review or formal investigation." She stated that Patient #1 and Patient #2's events were reviewed in the weekly Administrative Review Team meetings.
2. What is your audit process when an investigation has been conducted and actions have been put in place to review the effectiveness of those actions? The Chief Compliance Officer stated a formal investigation had been completed for Patient #1's event on 04/13/2024. She confirmed that since the investigation, Patient #1 had two reoccurrences of tying clothing around their neck, one of two which resulted in transfer to an acute care facility and one of two that was classified as no harm event. Patient #2 had one occurrence of tying clothing around their neck resulting in a transfer to acute care facility. No investigation for Patient #2's event was triggered.

G. During an interview on 07/03/2024 at 10:00 AM, the Chief Operations Officer confirmed the findings in A-E.