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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 §482.13 Condition of Participation: Patient's Rights, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on document review, interviews, and observations the facility failed to ensure patients with recent suicide attempts received care in a safe setting in one of two medical records reviewed for patients who attempted suicide in the 24 hours prior to admission (Patient # 2). Additionally, the facility failed to ensure patients were unable to access potentially harmful contraband in one of one medical records reviewed in which a patient obtained a knife he brought into the facility (Patient #5). (Cross Reference A-0283, A-0273)

Based on document review, interviews, and observations the facility failed to ensure patients with recent suicide attempts received care in a safe setting in one of two medical records reviewed for patients who attempted suicide in the 24 hours prior to admission (Patient # 2). Additionally, the facility failed to ensure patients were unable to access potentially harmful contraband in one of one medical records reviewed in which a patient obtained a knife he brought into the facility (Patient #5). (Cross Reference A-0283, A-0273)

Findings include:

Facility policies:

According to the policy Suicide Risk Assessment and Management, it is policy to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors. Patients at higher risk for suicide and/or self-destructive behavior require intensive support, active supervision, frequent re-assessment and indicated protective measures for their emotional and physical well being at all times.

The scope of the facility's suicide prevention activities include not only individual patient assessment and care that begins prior to admission and continues through the patient's discharge, but also the organization-wide measures taken to create a safe environment with well trained staff.

Assessment of risk: The admitting registered nurse (RN) on the unit will review the suicide risk assessment that has been completed by the intake staff. At the conclusion of the nursing assessment, the RN will document the individualized actions to take and precautions implemented which are applicable to the patient (based on his or her level of care) and contact the physician for appropriate orders including precautions, the level of observation, and any individualized interventions. The level of observation for suicide precautions will be determined based on the immediacy/seriousness of the risk presented by the patient. An RN may initiate suicide precautions or an increased level of observation while awaiting a formal order from the physician.

If a patient refuses to answer screening questions, the RN (or other evaluator) is still required to develop a formulation of risk. If the patient is determined to be at a higher risk, the RN (or other evaluator) will notify the psychiatrist of increased suicide risk and will determine appropriate orders and associated observations and/or interventions.

Suicide Screening - Intake Assessment: Intake/Admitting Staff will screen all patients presenting for admission using the Columbia-Suicide Severity Rating Scale (C-SSRS) which identifies specific patient characteristics that may indicate an increased risk of suicide.

If indicated by the C-SSRS screening tool, a full C-SSRS will be conducted by the Intake Staff. This assessment shall contain, at a minimum: Current or past thoughts of suicide; recent or past history of suicide attempts, evidence of suicidal planning or intent; clinical presentation/symptoms/behaviors; protective factors/deterrents; risk formulation including categorization of risk as compared to the general patient population, on the inpatient unit (lower, similar, or higher) and considerations made by the assessor for that categorization.

Suicide precautions are to be clearly indicated on the patient specific rounds sheets, and communicated during every transition of care (change of shift, breaks, and lunches) through thorough hand-off communication. Staff assigned to observe patients on suicide precautions shall be vigilant and immediately communicate to the charge nurse, who will then document, significant signs of concern such as suicidal statements or actions, attempts to elude staff observation, abrupt change in mood, either positive or negative, self-isolation, psychomotor agitation, global (prolonged) insomnia, attempts to gain access to dangerous items such as sharps or housekeeping chemicals, attempts to gain access to contraband, and any circumstantial life changes or triggers from past suicide attempts that the staff becomes aware of during the stay.

Staff may request that the patient make them aware of the need to use the restroom in order to maintain safety. Staff are to maintain a safe and therapeutic environment for all patients. Additional safety interventions are implemented for patients on suicide precautions. These interventions include, but may not be limited to: On admission perform a thorough search of the patient's clothing, personal articles, room and belongings to ensure that any items which might be used in a self-harmful way are confiscated. The patient's room may be searched as needed, with the physician's order and in compliance with facility policy and patient's rights. Remove all potential ligatures (shoelaces, belts, cords) and sharps (glass, razors, brittle plastic) from the environment. Additional safety measures should align with methods of suicide attempts, i.e., pencil restriction if a pencil was used for self harm, special observation for linens, room closer to nurses station. Completing environmental rounds and removing anything identified as a risk.

Nursing staff administering medications are to verify the ingestion of medication and possible "cheeking" or hoarding. Supervise visitation as determined on an individual basis by the physician. Visitors are informed that all personal items should be left in vehicles or secured in provided lockers. All items brought in by visitors for patients will be thoroughly searched before they are given to the patient. Acute: The patient will not be allowed outside privileges until evaluated for safety by the psychiatrist and a physician's order is written in the chart.

According to the policy Searches, contraband searches shall be conducted to reduce the entry of any items considered physically, emotionally, or psychologically dangerous, (i.e. potential weapons, sharp items, "cheeked" medications, literature believed to incite counter-therapeutic behaviors, drugs, etc.) into the patient program areas.

Procedure for room and unit searches. 1. Room/unit search may be completed as clinically indicated to assess for contraband and maintain a safe milieu. 2. If contraband is found, it is to be documented in the progress notes and on an incident report and stored in an area that is not accessible to patients. Any illegal contraband (drugs, weapons, etc.) found is to be given to the CEO or designee who in turn will see that it is destroyed or given to the proper authorities.

Notification requirements and contraband drug confiscation/destruction. Certain contraband items such as weapons, illegal drugs, matches, etc., will be confiscated by program policy. In all cases where contraband is found, the individuals performing the search shall report in writing on an incident report form the action taken, patient response, results, and any special events. This incident report shall be routed daily to the nurse executive.

According to the policy Control of Contraband, in order to provide a safe, secure environment, and to protect the safety of all patients and staff, the facility designated certain potentially dangerous items as 'contraband' and will remove all such items from the premises when they are discovered. Contraband is defined as any substance or item that is potentially dangerous to self or others. Some items listed as contraband are: glass, aerosol cans, products containing alcohol, drugs, matches, alcohol, cigarettes, knives, etc. Also, items that may be used as ligatures such as belts, shoelaces, drawstrings, scarves or any other lacing that secures clothing or shoes (ex. elastic or leather lacing or webbing that secures shoes). Any illegal substance is also considered contraband.

1. The facility failed to ensure precautions were in place to prevent an actively suicidal patient from making a suicide attempt shortly after admission onto the patient unit. Additionally, doors to private bedrooms were observed to be closed but unlocked on nursing units with actively suicidal patients who had expressed intent to hurt themselves.

A. Patient #2 attempted to hang himself approximately one hour after he was admitted to the facility. The facility directly admitted Patient #2 to a patient care unit; admissions staff gathered medical record information but did not assess him. Staff on the unit did not complete Patient #2's admission suicide risk assessment before allowing him access to a private room in which he was alone between staff observations every 15 minutes.

i. Document Review

a. Medical record review for Patient #2 revealed he was a direct admit to the nursing unit at the facility on 2/7/23 at 2:51 p.m. A physician wrote on Patient #2's discharge summary that on 2/6/23 police brought Patient #2 to a local emergency department (ED) on an involuntary psychiatric hold (M-1 hold) after he attempted to hang himself with his shoelaces in the bathroom of a convenience store. On the Emergency Mental Illness Report and Application (M-1 hold) form dated 2/6/23 at 7:00 p.m., a psychiatrist in the ED wrote Patient #2 was in imminent danger as he had told a police officer he did not want to live. Staff from the ED sent this document to the facility prior to the patient's admission.

Admissions staff at the facility wrote on the High Risk Notification Alert (a form used by the admissions staff to notify unit staff of a patient's high risk diagnoses or behaviors) that Patient #2 was at high risk for suicide. Admissions staff sent this form to the nursing unit on 2/7/23 at 11:01 a.m. Admissions staff sent an additional form to the unit indicating Patient #2's high risk for suicide. At 12:05 p.m., admissions staff sent the unit an Intake to the Unit Patient Report Worksheet indicating Patient #2 was at high risk for suicide, had attempted suicide by hanging, had a history of suicide attempts, and was diagnosed with recurrent, severe major depressive disorder. A registered nurse (RN) signed that the unit received the High Risk Notification Alert and the Intake to Unit Patient Report Worksheet but not until 9:46 p.m., approximately six hours after the patient had attempted to hang himself at the facility.

The policy Suicide Assessment and Risk Management read, for suicide precautions staff should have immediately communicated significant signs of concern. These signs included suicidal statements or actions and attempts to elude staff observation. Additional safety measures should have aligned with the patient's method of suicide attempts, including special observation for linens. Suicide precautions should have been clearly indicated on the patient's specific observation sheets, and should have been communicated during every transition of care (change of shift, breaks, and lunches) through thorough hand-off communication.

Patient #2 arrived on the nursing unit on 2/7/23 at 2:51 p.m. RN #1 quoted Patient #2 on the Nursing Admissions Assessment, "I don't want to be here. I don't want to be alive. I just want to be dead." She also wrote the facility admitted the patient in December of 2022 for the same concern. Additionally, RN #1 checked a box indicating Patient #2 required suicide and self-harm precautions. She dated this document 2/7/23 but did not include a time.

Review of Patient #2's observation sheets (documentation used to track a patient's behavior and location at a minimum of 15 minute intervals and as frequently as continuous observations) revealed the patient entered his private room shortly after admission. Documentation from the observation sheets showed staff checked on Patient #2 in his room every 15 minutes.

On 2/7/23, a nurse practitioner wrote a progress note that at approximately 4:00 p.m., staff called a code blue (a code used to indicate a patient needed immediate, emergency medical attention or life-saving interventions) after finding Patient #2 unresponsive on the floor of his room. The nurse practitioner wrote Patient #2 had tightly tied a blanket around his neck as a noose and his face was blue/purple. Staff unwrapped the blanket from his neck and he slowly regained consciousness. The nurse practitioner further wrote the patient had not required cardiopulmonary resuscitation (CPR, emergency procedures used to restart a person's heartbeat or breathing) but he did have a visible ligature (something used to bind) mark on his neck. The nurse practitioner sent the patient to an ED for assessment.

Emergency services staff wrote on the facility's Memorandum of Transfer Form that they left for the ED with Patient #2 on 2/7/23 at 4:17 p.m. Three minutes later, at 4:20 p.m., RN #1 wrote on Patient #2's Columbia Lifetime Suicide Risk Assessment (lifetime suicide risk assessment) that he had attempted to hang himself at the facility and therefore required interventions including suicide precautions, linen restrictions, cheek checks (to ensure he did not hide legally required medications in his cheek to avoid swallowing them), staff tracking of special anniversaries that could have prompted suicide attempts, and observations for hallucinations that could have prompted suicide attempts.

On 2/7/23 at 5:00 p.m., nursing staff entered a verbal order from a provider for a staff member to be in direct line of sight of Patient #2 at all times (1:1 observation). Additional verbal orders entered at 5:00 p.m. included suicide precautions and linen precautions (removing all blankets, sheets, towels or other linens that Patient #2 could have used in a hanging attempt).

Staff marked on the observation sheet that Patient #2 returned from the ED at 9:15 p.m., at which time facility staff started the 1:1 observations.

ii. Interviews

a. On 4/19/23 at 1:46 p.m., an interview was conducted with crisis clinician (Clinician) #2, an intake specialist in the admissions office. Clinician #2 stated either admissions or unit staff completed the Columbia-Suicide Severity Rating Scale (suicide screen) as part of the admission process. Clinician #2 explained the suicide screen was important as it triggered the lifetime suicide risk assessment. She further explained the lifetime suicide risk assessment provided information on how likely a patient was to attempt suicide. Clinician #2 said patients with a moderate or high risk for suicide on the lifetime suicide risk assessment required suicide precautions and other immediate interventions to prevent suicide attempts and self-harm.

On 04/24/2023 at 3:46 p.m., an interview was conducted with RN #1, during which she stated she had started the suicide screen for Patient #2 shortly after his arrival on the unit. She said Patient #2 would have triggered the lifetime suicide risk assessment, but she had not completed the suicide screen or started the lifetime suicide risk assessment before he refused to answer further questions.

Clinician #2 said admissions staff did not see patients in the admissions office if they transferred to the facility from another healthcare institution. Instead, transport crews dropped patients off directly to the nursing unit where unit staff completed the patient's first assessment. Clinician #2 explained as part of the direct-to-unit patient admission process, admissions personnel gathered information from the prior institution and created the patient's medical record. Clinician #2 stated creating the medical record included gathering information on precautions (interventions to increase patient safety), which were then transmitted via instant message to the nursing unit prior to the patient's arrival.

Clinician #2 said admissions staff transmitted the precaution information for Patient #2 on the High Risk Notification Alert and the Intake to Unit Patient Report Worksheet. Clinician #2 further stated as soon as the patient arrived on the unit the facility expected the RN to complete a suicide screen and the lifetime suicide risk assessment.

This interview was in contrast to the policy Suicide Risk Assessment and Management, which read intake/admitting staff should have screened all patients who presented for admission using the suicide screen, which identified specific patient characteristics that may have indicated an increased risk of suicide.

Clinician #2 said the admissions staff completed and sent the nursing unit Patient #2's High Risk Notification Alert and the Intake to Unit Patient Report Worksheet to ensure patient safety, protect the patient from suicide attempts and self-harm, and to act as a notification to staff that the patient required suicide and other precautions, such as observation rounds at an increased frequency.

b. On 4/19/23 at 1:46 p.m., an interview was conducted with care coordinator (Coordinator) #3, a staff member in the admissions office. Coordinator #3 said she had previously been employed by the facility as a mental health specialist (MHS) and therefore responded to the code blue that unit staff called for Patient #2 on 2/7/23. She stated that given the information available to unit staff at the time of his suicide attempt, he should not have been allowed off of common areas on the unit until staff obtained orders.

c. On 4/20/23 at 1:05 p.m., an interview was conducted with MHS #4. MHS #4 said as part of suicide precautions all doors on the unit should have been closed and locked to prevent an actively suicidal patient from having an opportunity to harm himself or herself. She explained MHS staff frequently checked doors to ensure they were locked. MHS #4 considered these checks to be a basic suicidal precaution. MHS #4 stated doors on the units should be closed and locked in order to increase patient safety and to prevent patients from accessing each other's rooms.

d. On 4/19/23 at 2:25 p.m., an interview was conducted with RN #5. RN #5 explained suicide precautions prompted staff to increase monitoring to prevent patient self-harm or suicide attempts. Given Patient #2's history, RN #5 said at a minimum staff should have kept him in common areas or on 1:1 observations. RN #5 stated if Patient #2 needed to use the bathroom, a staff member should have ben immediately outside the door. She explained staff should have continued these precautions until they understood Patient #2's safety needs so they would have been immediately available to prevent patient harm.

RN #5 said additional precautions for Patient #2 could have included a room block (not allowing the patient access to his room), linen precautions, or removing all clothing and providing the patient with scrubs that did not have ligature risk. RN #5 said the staff could have given Patient #2 a suicide blanket (a blanket made out of a material too stiff to wrap around the neck).

Upon review of Patient #2's medical record, none of the precautions listed by RN #5 were implemented prior to his suicide attempt.

e. On 4/24/23 at 3:46 p.m., an interview was conducted with RN #1. RN #1 stated Patient #2's suicide attempt concerned her because it occurred shortly after she had admitted him. RN #1 explained 2/7/23 had been a busy day with three admissions who arrived within a short time frame in addition to discharges and caring for existing patients. RN #2 said she completed Patient #2's body scan (a process whereby patients are searched for items forbidden on the unit) and had started his Nursing Admissions Assessment when Patient #2 said he was tired, refused to answer any more questions, and asked to go to his room.

RN #1 stated she had not yet completed Patient #2's lifetime suicide risk assessment when Patient #2 refused to answer further questions. As another admission arrived, RN #1 said she allowed Patient #2 to go to his room with observations every 15 minutes in place. She further said she had not communicated any assessment findings to the MHS assigned to observe the patient and had not asked the MHS to keep the patient out of his room with the door locked. RN #2 said she called the house supervisor and administration on 2/7/23 as she was feeling overwhelmed by tasks but did not receive help. RN #1 said at the time she was unaware actively suicidal patients should have been kept in common areas until the lifetime suicide risk assessment had been completed.

RN #1 explained if staff allowed actively suicidal patients to go into a room unobserved the patients could have hurt themselves. She stated in the 15 minutes between observation checks patients could have killed themselves or hurt somebody else.

This interview was in contrast to the Suicide Risk Assessment and Management policy, which read, patients at higher risk for suicide and/or self-destructive behavior required intensive support, active supervision, frequent re-assessment and indicated protective measures for their emotional and physical well being at all times.

The Suicide Risk Assessment and Management policy further read, the level of observation for suicide precautions should have been determined based on the immediacy/seriousness of the risk presented by the patient. An RN could have initiated suicide precautions or an increased level of observation while awaiting a formal order from the provider.

The Suicide Risk Assessment and Management policy also read if a patient refused to answer screening questions, the RN was still required to develop a formulation of risk. If the patient was determined to be at a higher risk, the RN should have notified the psychiatrist of increased suicide risk and determined appropriate orders and associated observations and/or interventions.

f. On 4/19/23 at 5:14 p.m., an interview was conducted with the director of nursing (Director) #6. Director #6 stated providers (nurse practitioners, physician assistants, or physicians) determined the need for 1:1 observation and other suicide precautions, although RNs were empowered by policy to initiate higher level precautions while awaiting orders.

Director #6 further stated if a patient had an unknown risk for suicide the facility expected staff to keep patients in common areas with the doors to private rooms closed and locked. She said staff should have continued this intervention until they understood the patient's risk for suicide. Upon request, the facility was unable to provide a policy which supported this statement. Director #6 said as psych nurses, the RN staff should have known to keep room doors closed and locked.

iii. Observations

a. On 4/19/23 at 3:15 p.m., observations were conducted on a unit that included an actively suicidal patient. The suicidal patient's door was closed but unlocked.

b. On 4/20/23 at 12:11 p.m., observations were conducted on a unit that included an actively suicidal patient. One door on the unit was not fully opened to allow staff a direct line of sight of the patient within the room. Instead, the door was only partially opened and the patient was behind the door.

c. On 4/22/23 at 1:20 p.m., observations were conducted on a unit that included an actively suicidal patient. A door to a private room was closed but unlocked.

These observations were in contrast with Director #6's and MHS #4's interviews, in which they stated staff should kept room doors closed and locked.

2. The facility failed to ensure patients did not have access to contraband such as weapons. Furthermore, staff failed to ensure contraband was confiscated from patient belongings prior to admission to the patient unit.

A. A patient accessed a pocket knife hidden in his belongings and used it to threaten another patient. The patient's belongings were stored in a locked storage closet in his room.

i. Document review

a. Medical record review for Patient #5 revealed he was a ten year old boy who had two recent admissions to the facility for increasingly aggressive behavior. Patient #5 had been admitted from 2/6/23 to 2/22/23 and again from 3/1/23 to 3/17/23. During these two admissions, staff documented at least eleven instances of Patient #5 displaying aggressive behavior. Examples included a Physician Daily Progress note dated 3/11/23, on which a doctor wrote Patient #5 had been transferred from the children's unit to the adolescent unit as he had been "extremely aggressive and impulsive" towards the younger patients on the children's unit. On 3/13/23 a registered nurse (RN) wrote on the Daily Nurse Progress note Patient #5 threw other patient's belongings around the unit and used aggressive, threatening language with other patients.

In a progress note on 3/7/23 at 1:00 p.m., an MHS documented Patient #5 got into a physical fight with another patient. After this fight Patient #5 initially threatened the other patient with a colored pencil. Patient #5 then opened the lock to the storage closet in his room with a plastic utensil and retrieved a pocket knife. He threatened the other patient with the knife. The patient who had received the threat reported the knife to staff, who confiscated and secured the weapon.

Medical record review revealed staff performed a contraband check on Patient #5's possessions on 3/1/23. Patient #5's Patient Possessions List (a document used to track possessions inventoried during contraband searches and at admission) did not include a pocket knife. A progress note on 3/7/23 at 1:00 p.m. revealed during the initial contraband check staff did not find a pocket knife the patient had hidden in his belongings prior to admission. The progress note further read Patient #5 gained access to this knife and used it to threaten another patient.

Patient #5 accessing contraband was in contrast to the policy Searches, which read contraband searches should have been conducted to reduce the entry of any items considered physically, emotionally, or psychologically dangerous (including potential weapons and sharp items) into the patient program areas. The Searches policy further read contraband should not have been stored in an area accessible to patients.

ii. Observations

On 4/19/23 at 2:19 p.m., observations were conducted within patient rooms. Each room observed revealed a storage closet secured by a deadbolt. The closets did not have a handle, but instead opened with the use of a key in the deadbolt.

iii. Interviews

a. In an interview conducted on 4/19/23 at 2:19 p.m., the director of performance improvement and risk management (Director) #7 stated staff used the storage closets within patient rooms to store patient clothing and other belongings patients were allowed to keep in the room according to the contraband policy. Director #7 explained staff kept the closets locked, the closets were only accessible by key, and that only staff members had access to the keys.

b. On 4/20/23 at 1:19 p.m., an interview was conducted with mental health specialist (MHS) #4. MHS #4 stated she had undergone training to search patient belongings. She explained the search process required staff to perform an organized, methodical check of patients and their belonging, including unlikely places such as inside the tongue of shoes or under bra linings. MHS #4 said she recalled providing care to Patient #5. MHS #4 said she believed Patient #5 was able to hide the knife from the search process because he was aware of how belongings were searched from his admission the month before. She explained Patient #5 hid the contraband plastic utensil from staff and used it to retrieve the knife on 3/7/23.

MHS #4 expressed concern about staff not correctly conducting contraband searches. She provided the example of Patient #5 hiding the knife in his belongings prior to admission and later gaining access to the knife to use it to threaten another patient. MHS #4 explained staff conducted contraband searches as part of the admission process, on each shift, and whenever staff suspected patients had hidden dangerous items. MHS #4 stated staff conducted contraband checks to increase patient and staff safety. She further added the contraband check process needed improvement, as some staff members did not perform the checks well.

c. On 4/24/23 at 3:46 p.m., an interview was conducted with RN #1. RN #1 stated staff needed to completely secure contraband, as patients could have used contraband to cause physical harm or death. RN #1 explained securing contraband was particularly important in the child and adolescent units, as the younger patients started hiding more items, became more aggressive, and escalated into fights more frequently if they felt they could hide contraband from staff.

RN #1 remembered caring for Patient #5. She explained his parents had allowed him to pack his own bag to come to the facility and he may have packed the knife with the intention of hurting himself or someone else because he did not want to undergo another admission.

RN #1 stated she had concerns regarding the quality of contraband searches. She said she had witnessed incidents in which contraband items were discovered by staff at the time of discharge as they used the admission inventory to return items to patients. RN #1 explained the risks of not conducting a thorough search included patients sneaking potentially dangerous into the facility, which could lead to patient harm.

d. On 04/24/2023 at 2:02 p.m., an interview was conducted with the director of performance improvement and risk management (Director) #7. Director #7 stated leadership should have conducted a review of Patient #5's admission process to understand how the contraband was missed during contraband searches conducted on 3/1/23. She stated she questioned if staff followed the inventory process and simply missed the knife, or if they had bypassed the process.

e. On 04/25/2023 at 8:44 a.m., an interview was conducted with director of nursing (Director) #6. Director #6 stated staff performed contraband searches to to ensure safety for patients, visitors, and staff. She explained the facility had been planning on adding refresher training for staff to be held every six months, but had not yet done so as the trainer was developing the curriculum.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 Condition of Participation: Quality Assessment and Performance Improvement Program, was out of compliance.

A-0273 The hospital must measure, analyze, and track quality indicators ...and other aspects of performance that assess processes of care, hospital service and operations. Based on document review and interviews, the facility failed to ensure the quality assessment and performance improvement program measured, analyzed, and tracked quality indicators. Specifically, the facility failed to ensure staff members had access to enter adverse patient events. (Cross Reference A-0144)

A-0283 The hospital must use the data collected to identify opportunities for improvement and changes that will lead to improvement. The hospital must set priorities for its performance improvement activities that affect health outcomes, patient safety, and quality of care. Based on interviews and document review, the facility failed to use data collected from adverse patient safety events to identify opportunities for improvement and changes that would have led to improvement as well as set priorities for performance improvement activities that affected health outcomes, patient safety, and quality of care. Specifically, during the performance improvement process the facility failed to recognize gaps in the policies and/or procedures in one of one records reviewed of an actively suicidal patient who attempted to hang himself shortly after admission (Patient #1). (Cross Reference A-0144)

Based on document review and interviews, the facility failed to ensure the quality assessment and performance improvement program measured, analyzed, and tracked quality indicators. Specifically, the facility failed to ensure staff members had access to enter adverse patient events (Cross Reference A-0144)

Findings include:

Facility policies:

According to the Reporting and Documenting Untoward/Unusual events policy, complete appropriate incident reports and route immediately to the risk manager. Appropriate communication and documentation of unusual occurrences will take place in order to intervene immediately and responsibly when action is indicated, and to provide high quality, ethical care to patients.

According to the Incident Reporting policy, the purpose of an incident reporting process is to: A. support timely and accurate reporting of serious injuries, unexpected outcomes, suspected violations of law or federal/state regulations, or other mandatory reporting situations (i.e. EMTALA, HIPAA, CMS) as may be required. B. ensure immediate actions are taken to prevent potential for further incident/injury or incident reoccurrence. C. Investigate incidents in a timely manner to identify and implement patient safety improvement and prevention strategies. D. Provide and implement a standardized and consistent reporting process within each facility to improve patient safety. E. Provide a database for trending analysis of reported incidents to improve patient safety.

An incident is an event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results or could have resulted (near miss) in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment.

An incident report must be completed for any event occurring to consumers or visitors that is not within the normal course of activities. An incident report should be completed by the person most knowledgeable of the event as soon as possible following the incident, but before the end of the shift in which the incident occurred.

1. The facility failed to ensure adverse patient events were reported.

A. Record Review

a. The medical record was reviewed for Patient #5. A Progress Note dated 3/7/23 documented a fight between Patient #5 and another patient. Mental health specialist (MHS) #4 documented Patient #5 accessed a locked storage closet which contained his belongings, retrieved a pocket knife he had hidden and threatened to stab the other patient.

i. According to the Incident Reporting policy, an incident was an event, outcome, or situation that was not consistent with routine care of patients and/or the desired operations of the facility and resulted or could have resulted in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment.

An incident report must be completed for any event occurring to consumers or visitors that is not within the normal course of activities.

The purpose of the incident reporting process was to support timely and accurate reporting of serious injuries, unexpected outcomes, suspected violations of law or federal/state regulations; ensure immediate actions were taken to prevent potential for further incident/injury or incident reoccurrence; and to allow investigation of incidents in a timely manner to identify and implement patient safety improvement and prevention strategies.

ii. The facility was unable to provide any evidence or documentation of an "incident report" for Patient #5.

This was in contrast to facility policy.

B. Interviews

a. On 4/22/23 at 12:53 p.m., an interview was conducted with MHS #9. MHS #9 stated if she needed to report a patient safety event, she would ask one of the nurses to enter a report as she did not have access to the incident reporting system. MHS #9 stated she had verbally reported the incident regarding the nonfunctioning locks to the charge nurse, but was unsure if a report had been filed.

b. On 4/20/23 at 1:05 p.m., an interview was conducted with MHS #4. MHS #4 stated the MHS' process for entering patient safety events was to add a detailed explanation to the patient's medical record. She stated MHS staff were unable to fill out an incident report. MHS #4 explained the MHS staff reported concerns to the nursing staff, and the nurse would complete the report. MHS #4 stated she completed the detailed explanation for the incident of Patient #5 gaining access to the knife and placed it in the medical record, but after she discussed it with the RN an incident report was not completed.

The interviews with MHS #9 and MHS #4 were in contrast to the Incident Reporting policy which read, an incident report should have been completed for any event occurring to patients or visitors that was not within the normal course of activities. An incident report should have been completed by the person most knowledgeable of the event as soon as possible following the incident, but before the end of the shift in which the incident occurred.

c. On 4/24/23 at 12:27 p.m., an interview was conducted with nurse educator (Educator) #10. Educator #10 stated all staff members, including MHS staff, received training on the incident reporting system during the first week of orientation. She stated anybody and everybody employed by the facility could report an incident. However, Educator #10 state if the MHS did not have the ability to enter an incident report, they had been trained to write detailed reports on a progress note. The MHS should then give the report to a milieu specialist (a staff member trained to maintain a calm, safe, therapeutic patient environment), the educator herself, an RN, or the nursing supervisor to have the report entered into the system.

This interview was in contrast to the Incident Reporting policy, which read an incident report should have been completed by the person most knowledgeable of the event.

Additionally, the interview with Educator #10 was in contrast to the interviews with MHS #4 and MHS #9 who stated they did not have access to the incident reporting system.

d. On 04/25/2023 at 8:44 a.m., an interview was conducted with director of nursing (Director) #6. Director #6 stated the facility used incident reports to assure the safety of patients and staff, provide redirection or coaching to staff, to review process failures, and to make process changes to prevent further incidents. Director #6 stated the patient safety event where Patient #5 obtained a knife at the facility, should have been reported to allow follow up for the process and staff education. She stated the purpose of updating and reviewing processes was to increase patients' safety by not allowing them access to things that could potentially harm them.

According to the Reporting and Documenting Untoward/Unusual events policy, appropriate incident reports should be immediately completed and routed to the risk manager. Appropriate communication and documentation of unusual occurrences should have taken place in order to intervene immediately and responsibly when action was indicated, with the intention of providing high quality, ethical care to patients.

Based on interviews and document review, the facility failed to use data collected from adverse patient safety events to identify opportunities for improvement and changes that would have led to improvement as well as set priorities for performance improvement activities that affected health outcomes, patient safety, and quality of care. Specifically, during the performance improvement process the facility failed to recognize gaps in the policies and/or procedures in one of one records reviewed of an actively suicidal patient who attempted to hang himself shortly after admission (Patient #1). (Cross Reference A-0144)

Findings include:

Facility policies:

According to the policy Suicide Risk Assessment and Management, assessment of risk: The admitting registered nurse on the unit will review the suicide risk assessment that has been completed by the intake staff.

If a patient refused to answer screening questions, the RN was still required to develop a formulation of risk. If the patient was determined to be at a higher risk, the RN should have notified the psychiatrist of increased suicide risk and determined appropriate orders and associated observations and/or interventions

According to the Incident Data Gathering and Reporting (Risk Management) policy, an individual designated by the CEO will maintain a patient safety work product file on each serious incident containing information such as: a. Documentation of the incident. b. Conclusions of incident reviews. c. Any documents relevant to the event (i.e., staffing schedules, code blue logs, informal shift notes, etc.). d. Any physical evidence of the incident. e. Any interviews that are conducted.

According to the Investigating Serious Incidents, Allegations, and Near Misses policy, a near miss is an event or situation that did not produce patient injury, but only because of chance (i.e. a good catch or close call).

Upon gathering available data related to the event, the risk manager will analyze the incident, consulting with other management or clinical personnel as needed. The analysis may use tools such as root cause analysis, intensive analysis, and/or a near miss analysis to the extent appropriate. That is, analysis should focus on identifying not only the direct cause(s) of the incident but also on identifying any underlying causes that may reflect process or systems issues in need of further review. a. When incident investigations reveal processes or systems in need of improvement, these findings will be communicated to the Patient Safety Council, the Patient Safety Organization of the facility. The risk manager will assure that the Patient Safety Council addresses such issues and that actions are taken for improvement where appropriate.

Near miss investigation: Near miss occurrences or investigations may not be reported to the Joint Commission, but corrective action documentation/associated analysis shall be filed and available for review by Joint Commission/CMS surveyors.

1. The facility failed to follow process improvement policy by not reviewing underlying causes that may have reflected process or systems issues in need of further review. Specifically, the facility failed to provide documentation of comprehensive follow up after Patient #2 attempted suicide shortly after direct admission onto a nursing unit.

i. Medical record review revealed Patient #2 attempted suicide by hanging on 2/6/23. Police officers brought him to a local emergency department (ED); the ED transferred Patient #2 to the facility on 2/7/23 at 2:51 p.m. The facility's admission staff gathered Patient #2's medical information but did not fill out any assessment data, including a suicide risk assessment. Transportation staff brought the patient directly to the patient care unit per the facility's expectations. Registered nurse (RN) #1, a bedside nurse on the unit, began Patient #2's admission assessment, including suicide risk screening, but did not complete the paperwork as the patient complained of being tired and refused to answer further questions.

Further review of the medical record revealed no evidence of a higher level of observation or other suicide prevention measures implemented before allowing Patient #2 access to his private room. Staff observed Patient #2 in his room every 15 minutes until approximately an hour later, at 4:00 p.m., he again attempted suicide by tightly tying a blanket around his neck. Additionally, the medical record showed the RN did not obtain provider orders for level of observation or other suicide precautions until after the patient had attempted suicide. There was no evidence the RN communicated the high risk for suicide with the mental health specialist (MHS) assigned to monitor the patient. After Patient #2 attempted to hang himself, a nurse practitioner ordered staff to send him to an ED for medical clearance. Patient #2 returned to the facility on the evening of 2/7/23.

This event was in contrast to the Suicide Risk Assessment and Management policy, which read the admitting RN on the unit should have reviewed the suicide risk assessment that had been completed by the admissions staff.

The Suicide Risk Assessment and Management policy also read if a patient refused to answer screening questions, the RN was still required to develop a formulation of risk. If the patient was determined to be at a higher risk, the RN should have notified the psychiatrist of increased suicide risk and determined appropriate orders and associated observations and/or interventions.

ii. On 04/19/23 at 5:17 p.m., an interview was conducted with director of nursing (Director) #6. Director #6 stated her biggest concern regarding Patient #2's suicide attempt was that the RN had not communicated the high risk for suicide to the MHS. When asked what had been implemented to ensure suicidal patients did not have opportunities to harm themselves, Director #6 said the nursing staff had been re-educated about communication at a nursing staff meeting and that if another suicide attempt occurred she would again re-educate staff. Director #6 also stated she had implemented huddle boards (whiteboards intended to convey patient information) on each unit.

When asked what had been implemented to ensure suicide risk screening was completed prior to staff allowing patients away from direct observations, Director #6 said as psychiatric specialists the RNs should have known to keep patients in common areas with unit doors closed and locked. Director #6 said the facility had a policy regarding ongoing observation of patients until staff understood their safety needs.

When requested, the facility was unable to provide this policy.

iii. On 04/24/23 at 3:46 p.m., an interview was conducted with RN #1. RN #1 stated she was not aware of any policy and had not been educated that suicidal patients should not have been allowed access to their rooms until after they cooperated with suicide risk screening. RN #1 said after the event, she was asked one or two questions by Director #6 and then the two of them reviewed mistakes RN #1 had made on admission paperwork.

iv. On 4/24/23 at 2:44 p.m., an interview was conducted with the director of performance improvement and risk management (Director) #7. Director #7 said if the facility took action on an incident report (documentation of unusual occurrences within the facility) the actions taken would have been included in the report itself. She stated if patient harm did not occur then she would investigate for a process failure to identify breakdown. Director #7 stated she did not consider Patient #2's suicide attempt a near miss, as he had been medically cleared from injury at the ED. She stated the process for prevented suicide attempts worked because staff had found Patient #1 before he suffered injury.

This interview was in contrast to the Investigating Serious Incidents, Allegations, and Near Misses policy,which read a near miss was an event or situation that did not produce patient injury, but only because of chance (i.e. a good catch or close call).

v. Review of the incident report for Patient #2's suicide attempt revealed a description of the event and documentation of the interventions implemented after Patient #2 returned to the facility. When asked for follow up for the incident regarding Patient #2's suicide attempt, the facility provided a RN/LPN Nursing Meetings - 1st Quarter 2023 meeting agenda. The facility was unable to provide documentation of interviews with RN #1, conclusions of incident reviews, or any physical evidence from the incident. Further, the facility was unable to provide analysis of the incident; a root cause, intensive, or near miss analysis; or identification of any underlying causes that may have reflected process or system issues in need of further review.

This was in contrast to the facility policy Incident Data Gathering and Reporting (Risk Management), which read an individual designated by the CEO should have maintained a patient safety work product file on each serious incident containing information such as: a. Documentation of the incident. b. Conclusions of incident reviews. c. Any documents relevant to the event (i.e., staffing schedules, code blue logs, informal shift notes, etc.). d. Any physical evidence of the incident. e. Any interviews that were conducted.

This was also in contrast to the Investigating Serious Incidents, Allegations, and Near Misses policy, which read upon gathering available data related to the event, the risk manager should have analyzed the incident and consulted with other management or clinical personnel as needed. The analysis may have used the tools such as root cause analysis, intensive analysis, and/or a near miss analysis to the extent appropriate. Analysis should have focused on identifying not only the direct cause(s) of the incident but also on identifying any underlying causes that may have reflected process or systems issues in need of further review.

vi. Review of the RN/LPN Nursing Meetings - 1st Quarter 2023 meeting agenda revealed the educator discussed the facility expectations for completing admission paperwork, including properly completing the suicide assessment. The educator also discussed communication expectations on the units and the implementation of the huddle boards. The meeting agenda did not discuss facility expectations for staff to observe suicidal patients until they understood patient safety factors.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §416.46 NURSING SERVICES was out of compliance.

A-0392 (b) STANDARD: STAFFING AND DELIVERY OF CARE The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on interviews and document reviews, the facility failed to ensure an adequate number of nursing staff were present on each inpatient unit to meet the needs of the patients. Specifically, the facility failed to ensure inpatient units were staffed according to patient acuity and current patient census. The failure was identified in one of five inpatient units.

Based on interviews and document reviews, the facility failed to ensure an adequate number of nursing staff were present on each inpatient unit to meet the needs of the patients. Specifically, the facility failed to ensure inpatient units were staffed according to patient acuity and current patient census. The failure was identified in one of five inpatient units.

Findings include:

Facility policy:

The Master Staffing Plan/Nurse Staffing Committee policy read, a core number of nursing staff shall be on duty at all times. Nursing staff will be adjusted for census and patient acuity. A sufficient number of qualified nursing staff will be on duty at all times to provide the required level of skilled care and nursing judgment. The overall purpose of the Master Nurse Staffing Plan is to ensure the hospital is adequately staffed and the healthcare, safety, and welfare needs of patients and staff are met. Many factors are considered when developing the Master Nurse Staffing Plan including current best practices, evidenced-based metrics, patient census, patient acuity/workload, patient churn (admits, discharges, transfers) on the inpatient units, RN education, patient outcomes, and workforce metrics/staff feedback. The Nurse Executive establishes the necessary number and type of staff needed to provide quality care and ensure a safe environment. The employment, deployment, and assignment of staff are approved by the Chief Nursing Officer or designee. An acuity classification system will be used to determine when staffing needs may be increased based on patient care and acuity indicators. This can be implemented by the unit charge nurse and approved by the house supervisor. Notification of increased staffing needs should be made to the nursing administration.

Reference:

The Nursing Department Staffing Grid, provided by the facility, listed each inpatient unit at the facility and specified the variable patient census range for each inpatient unit, and the specified number of Registered Nurses (RN) and Mental Health Specialists (MHS) expected to be staffed and present on each inpatient unit according to the current patient census. The Staffing Grid for the Birchwood/Ponderosa inpatient unit specified one RN was required to be scheduled and present on the unit when the patient census was less than or equal to 14 patients. Additionally, two RNs were required to be scheduled and present on the unit when the patient census was greater than 15 patients.

1. The facility failed to staff inpatient units according to facility policy and guidelines.

a. Patient Care Assignment Sheets and patient census (unit census) for the Birchwood/Ponderosa unit were reviewed from 2/1/23 to 4/17/23 and revealed inpatient units were not staffed according to facility policy and the Nursing Department Staffing Grid (Staffing Grid). Examples include:

i. On 4/10/23 from 7:00 a.m. to 3:00 p.m., the Birchwood/Ponderosa unit census was 22 patients, and from 3:00 p.m. to 7:00 p.m., the patient census was 20 patients. The Daily Guideline staffing sheet revealed one RN had been present on the unit from 7:00 a.m. to 7:00 p.m.

ii. On 4/6/23 the Birchwood/Ponderosa had a unit census of 18 patients from 7:00 a.m. to 3:00 p.m. The Daily Guideline staffing sheet for 4/6/23 revealed one RN was staffed and present on the unit.

iii. From 11:00 p.m. to 7:00 a.m. on 3/17/23, the Birchwood/Ponderosa unit census was 18 patients. A review of the Daily Guideline staffing sheet for 3/17/23 revealed from 2:15 a.m. to 7:00 a.m. one RN was staffed and present on the unit.

iv. On 3/16/23 between 7:00 a.m. to 3:00 p.m., the Birchwood/Ponderosa unit census was 18 patients. The Daily Guideline staffing sheet for 3/16/23 revealed one RN was staffed and present on the unit.

b. Further review of the Daily Guideline staffing sheets for the Birchwood/Ponderosa unit revealed additional days the unit did not have nurses staffed on the unit according to the Staffing Grid.

i. On 2/5/23, 2/14/23, 3/8/23, 3/9/23, 3/10/23, and 3/14/23 from 3:00 p.m. to midnight on each day more than 15 patients were present on the Birchwood/Ponderosa unit.

A review of the Staffing Grid revealed, two RNs were required to be staffed and present on the unit when the number of patients on the unit equaled more than 15 patients. According to the Daily Guideline staffing sheets for 2/5/23, 2/14/23, 3/8/23, 3/9/23, 3/10/23, and 3/14/23, one RN was scheduled and present on the unit.

ii. From 12:00 a.m. to 7:00 a.m. on 3/9/23 and 3/15/23 there were 19 patients on the Birchwood/Ponderosa unit and on 2/6/23, 2/15/23, and 3/10/23 there were 18 patients on the Birchwood/Ponderosa unit.

According to the Staffing Grid, two RNs were required to be staffed and present on the unit when 15 patients or more patients were on the unit. A review of the Daily Guideline staffing sheets for 2/6/23, 2/15/23, 3/9/23, and 3/15/23 revealed one RN was scheduled and present on the unit.

iii. On 2/26/23 from 7:00 a.m. to 3:00 p.m., the patient census on the Birchwood/Ponderosa unit was 19 patients, additionally, on 2/15/23 and 2/25/23 the patient census was 17 patients.

The Daily Guideline staffing for 2/15/23, 2/25/23, and 2/26/23 revealed one RN was staffed and present on the unit. However, the Staffing Grid required two RNs to be staffed and present on the unit.

These examples were in contrast to facility policies and guidelines. According to the Master Staffing Plan/Nurse Staffing Committee policy, the Nursing Department Staffing Grid for each inpatient unit nursing personnel were staffed on the unit based on the acuity expected for the unit's defined patient population. Additionally, the unit would be staffed with a sufficient number of qualified nursing staff needed according to the patient census, the Nursing Department Staffing Grid, and patient acuity.

c. Interviews were conducted with facility staff and revealed inpatient units were continuously understaffed and nursing staff were concerned for patient safety.

i. On 4/17/23 at 11:24 a.m., an interview was conducted with RN #11. RN #11 stated recently the Birchwood/Ponderosa unit had a patient census of 22 patients with one RN staffed to care for all of the patients. RN #11 stated she had worked several days on the unit short-staffed due to staff call-outs. RN #11 stated patient self-harm increased as a result of inadequate staffing of nursing personnel. RN #11 stated mental health patients required a sufficient number of nurses to be present on the inpatient unit to ensure the mental health needs of the patient were addressed. RN #11 stated there was a risk of potential harm to patients when units were short-staffed.

ii. On 4/24/23 at 3:46 p.m., an interview was conducted with RN #1. RN #1 stated she worked several days short-staffed. RN #1 stated the use of patient restraints increased as a result of inadequate staffing of nursing personnel. RN #1 stated escalation of aggressive, hostile, and assaultive patient behaviors could have been avoided had a sufficient number of nursing personnel been present on inpatient units.

iii. On 4/25/23 at 8:35 a.m., an interview was conducted with the director of nursing (DON) #6. DON #6 reviewed the Nursing Department Staffing Grid. DON #6 stated inpatient units were supposed to be staffed according to the Nursing Department Staffing Grid.

DON #6 stated the Nursing Department Staffing Grid listed the number of nurses who should have been present on the unit to care for patients according to the unit census and patient acuity level.

DON #6 stated according to the Nursing Department Staffing Grid, two nurses should have been present on the Birchwood/Ponderosa unit when the unit census was greater than 14 patients. However, DON #6 stated she was aware the Birchwood/Ponderosa unit had been understaffed on numerous dates and the facility was unable to consistently staff the Birchwood/Ponderosa unit according to the Nursing Department Staffing Grid. DON #6 further stated patients had an increased risk of harm when units were not properly staffed.