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Based on observation, medical record review, staff interview, review of video surveillance recording, and review of facility documents, it was determined that the facility failed to ensure that 1). patients on 1:1 observation are within direct visualization and continuous supervision at all times (A0144); 2.) a suicide risk assessment is provided for patients who are at risk for suicide or self-harm, in one of four medical records reviewed (A0144); 3). patients who are identified as high risk for suicide or harm (to self or others) are placed on 1:1 observation, in one of four medical records reviewed (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

On 10/29/25 at 3:55 PM, an IJ was identified for the facility's failure to ensure that patients on 1:1 observation are within direct visualization and continuous supervision at all times. On 10/29/25 at 4:45 PM, the IJ template was presented to Administration, and a removal plan was requested.

On 10/30/25 an acceptable removal plan was received. The facility implemented the following to address the IJ: the current policy was revised to clearly outline the expectations of monitoring a patient who is ordered to be on a one-to-one observation and requests to use the restroom. An attestation was developed outlining the expectations for each therapeutic sitter to read and sign prior to initiating a one-to-one with a patient at risk for self-harm. A read-and-sign huddle was conducted for all Emergency Department nurses and therapeutic sitters. The huddle outlined the findings of the IJ, policy revisions, and the new attestation process for therapeutic sitters. The education and huddle is to continue each shift until all Emergency Department nurses and therapeutic sitters are educated prior to the start of their shift. An Emergency Department restroom was chosen and closed off as of 10/30/25 to begin immediate construction and modifications for the implementation of a behavioral health-safe restroom. The IJ was removed on 10/30/25 at 12:00 PM, after the State Agency verified implementation of the removal plan.
Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on observation, medical record review, staff interview, review of video surveillance recording, and review of facility documents, it was determined the facility failed to ensure that 1). patients on one-to-one observation are within direct visualization and continuous supervision at all times; 2). a suicide risk assessment is conducted for patients who are at risk for suicide or self-harm, in one of four medical records reviewed; 3). patients who are identified as high risk for suicide or harm (to self or others) are placed on 1:1 observation, in one of four medical records reviewed.

Findings include:

1. Facility policy titled, "Therapeutic Sitter (1:1) Observation, A138," stated, "... Scope: 1. Responsibility... Emergency Department (ED) patients who require one-to-one (1:1) monitoring behaviors by staff ... d. Therapeutic Sitter One-to-one (1:1) Sitter: Continuous 1:1 monitoring ... for a patient who presents an immediate or actual threat of harm to themselves ... The patient remains within direct visualization and continuous supervision at all times ... Special Considerations for the Patient Requiring Continuous Monitoring 1. The patient must remain within direct visualization and continuous supervision at all times, including while in the bathroom ... the Therapeutic Sitter must accompany the patient at all times ..."

On 10/29/25 at 10:38 AM, a tour of the Emergency Department (ED) was conducted in the presence of Staff (S)3 and S4. During the tour, S8 was observed conducting a therapeutic one-to-one observation with a patient of the opposite gender. At 10:46 AM, upon interview, S8 stated if the patient needed to use the restroom, S8 would ask another staff member who was of the same gender as the patient to accompany the patient to the restroom. S8 stated that with a therapeutic one-to-one level of observation, the patient must be visible at all times and the patient cannot be in the restroom alone or with the door closed.

At 10:51 AM, during an interview, S9 confirmed that patients who have a one-to-one level of observation will always have a staff member with the patient and that the patient can never be left alone. S9 further stated that if a patient on a one-to-one need to use the restroom, a staff member must accompany the patient and have eyes on the patient at all times.

On 10/29/25 at 2:27 PM, an ED restroom labeled "E1519A" was toured in the presence of S2, S4, and S5. Several ligature risks were identified in the restroom including a sink faucet, a toilet seat, a grab bar, a door handle, and a trash can with a plastic bag in it. On 10/29/25 at 2:31 PM, an ED restroom labeled "E1517A" was toured in the presence of S2, S4, and S5. Several ligature risks were identified in the including a sink faucet, a toilet seat, a grab bar, a door handle, and a trash can with a plastic bag in it. Upon interview, S4 confirmed that the ED restrooms E1519A and E1517A had potential ligature risks and presented a risk for harm of a patient if a suicidal patient was left unattended in these rooms.

On 10/29/25 at 1:07 PM, P1's medical record was reviewed in the presence of S12 and revealed the following:

On 10/19/25 at 7:55 PM, P1 arrived in the ED for complaints of suicidal ideation (SI). At 8:09 PM, a Columbia Suicide Severity Rating Scale [C-SSRS] assessment was performed and revealed the following:
1. Wish to be Dead: Yes
2. Suicidal Thoughts: Yes
3. Suicidal Thoughts with Method Without Specific Plan or Intent to Act: No
4. Suicidal Intent Without Specific Plan: No
5. Suicide Intent with Specific Plan: Yes ...
C-SSRS Risk Level: High ...

On 10/19/25 at 8:09 PM, the ED triage notes documented by a Registered Nurse (RN) revealed that P1 had a plan to jump out of a second-floor window and had a previous suicide attempt in September 2025.

On 10/20/25 at 12:57 PM, a physician documented in the "ED Course and MDM [Medical Decision Making]" log and revealed the following: "Patient was found with a part of top of cup in hand, was going to cut [self] but this was seen by a nurse and it was taken from [the patient] before [the patient] tried to cut [self] ... reports that if [the patient] went back to the group home, [the patient] 'already has a plan' for how [they] would kill [self] ..."

On 10/22/25 at 5:18 PM, a physician documented in the "ED Course and MDM [Medical Decision Making]" log which stated, "Patient becoming agitated. Starting to take things off the walls in [his/her] room and threatening to hurt [self] ..."

On 10/24/25 at 8:27 PM, a physician documented in the "ED Course and MDM [Medical Decision Making]" log which stated, "Just alerted that when the patient went to the restroom [the patient] cut [his/her] arms with a piece of plastic from the cup ..."

On 10/24/25 at 8:37 PM, a nursing note documentation stated, "1:1 notified this RN that pt [patient] cut [himself/herself] in the bathroom. Pt with three new cuts to left forearm ..."

On 10/29/25 at 3:22 PM, the ED surveillance video recording was reviewed in the presence of S2 and S15 and revealed the following:

On 10/24/25 at 7:51:45 PM, P1 was observed standing up from the hospital stretcher and walked toward the staff member conducting the 1:1 observation. S15 identified the staff member S26 present in the video footage as the patient's assigned therapeutic 1:1 observer, and that the patient present in the video footage was P1.

At 7:53:08 PM, S26 was observed opening the ED restroom door and waved P1 into the restroom. P1 entered the restroom and closed the door after entering. The therapeutic 1:1 observer was observed standing outside of the restroom. During the video surveillance review, S26 was not observed to perform a safety check of the environment prior to P1 entering the restroom.

At 7:56:37 PM, P1 exited the ED restroom.

P1 was in the restroom for three minutes and 29 seconds without direct observation of the therapeutic sitter.

On 10/29/25 at 3:51 PM, upon interview, S15 confirmed the above findings at the time of discovery and stated the patient should not have been left alone and out of sight in the restroom because of their level of observation and high risk of suicide.

2. Facility policy titled, "Suicide Risk Assessment & Prevention, S-8," stated, " ... Purpose: ... 1. The identification of patients who are at risk for suicide or self-harm ... Policy: Risk factors that may increase the likelihood of patient self-harm include ... a. Verbalization of clear intent to harm self or expresses suicidal thoughts, plans, or plans for final arrangements ... 2. The Columbia Suicide Severity Rating Scale (C-SSRS) is utilized to screen for a patient's risk for suicide upon arrival to the ED ... 5. The clinical nurse implements 1:1 patient observation (therapeutic sitter) upon identification of a patient at a high level of risk until the provider determines clinical management and interventions ..."

On 10/29/25 at 12:14 PM, a review of P3's medical record revealed the following:

On 10/15/25 at 3:43 PM, P3 arrived in the ED accompanied by police officers and reported they "didn't want to live anymore," per the nursing ED triage note. The patient's chief complaint was documented as "suicidal."

The medical record lacked evidence that a Columbia Suicide Severity Rating Scale [C-SSRS] assessment was performed during triage.

10/29/25 at 2:39 PM, upon interview, S5 confirmed the above findings and stated that the C-SSRS should have been completed during triage and that the patient was at risk of self-harm. S5 stated a therapeutic one-to-one observer should have been implemented immediately.

3. Facility policy titled, "Therapeutic Sitter (1:1) Observation, A138," stated, "... Scope: ... 2. Definition of Terms: ... d. Therapeutic Sitter One-to-one (1:1) Sitter: Continuous 1:1 monitoring by a qualified staff member for a patient who presents as an immediate or actual threat of harm to themselves ..."

On 10/29/25 at 12:14 PM, a review of P3's medical record revealed the following:

On 10/15/25 at 3:43 PM, P3 arrived in the ED with a chief complaint documented as "suicidal."

On 10/15/25 at 4:18 PM, a Nursing ED Note indicated the patient was changed into scrubs and that security was called for "wanding" and a belongings search. The nurse documented that a police officer was at the bedside with P3.

On 10/29/25 at 12:44 PM, during an interview with S11 and S12, S11 was asked if a police officer qualifies as a 1:1 therapeutic observer for suicidal patients. S11 stated that a police officer does not count as a patient's 1:1 observer and that it must be a staff member. S12 agreed with S11's statement.

On 10/29/25 at 2:39 PM, P3's medical record was reviewed with S5. During the review, S5 stated the C-SSRS should have been conducted on this patient and that a police officer did not qualify as a patient's 1:1 observer.

On 10/29/25 at 2:40 PM, upon interview, S5 confirmed the above findings at the time of discovery and stated that only qualified staff members may act as a therapeutic one-to-one observer for patients who require 1:1 observation.