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Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that psychiatric patients were safe from ligature risks; potentially dangerous items were removed from patients' rooms; and the appropriate level of patient safety monitoring was in place for suicidal patients. 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 patient rooms on the Behavioral Health Units were free from ligature risks to prevent harm to the patients. (A 144-A)

2. The Hospital failed to ensure that potentially dangerous items were removed from the patient rooms. (A 144-B)

3. The Hospital failed to ensure that the appropriate level of patient safety monitoring was in place, in accordance with Hospital policy. (A 144-C)

An Immediate Jeopardy (IJ) began on 7/26/18 (date of Hospital's identification of ligature risks), for the Hospital's failure to remove ligature risks, identify potentially hazardous items, and ensure the appropriate level of patient safety monitoring, thus placing all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 3/26/19 at 12:35 PM, during a meeting with the Senior Patient Safety Officer, Assistant Vice President of Regulatory and Clinical Effectiveness, Accreditation Manager, Vice Chair of Department of Psychiatry/Director of Clinical Services/Medical Director Adult Inpatient Psychiatry, Associate Vice President of Nursing, Associate Chief Medical Officer, Assistant Vice President of Behavioral Health/Nursing Orientation. The IJ was not removed by the survey exit date of 3/26/19.

A. Based on document review, observation, and interview, it was determined that for 3 of 3 Behavioral Health Units (8N - Adult, K4 - Child and Adolescent, and K13 - Adult), the Hospital failed to ensure that patients' rooms were free from ligature risks. This could potentially affect any current (census of 20 patients on 3/21/19) and future patients on the units who become suicidal.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08,2017, reviewed on 7/25/18 at approximately 2:00 PM 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..."

2. The Hospital's policy titled, "Patient Rights and Responsibilities" (approved 3/11/19) was reviewed on 3/21/19 and required, "...A patient has the right to receive care in a safe setting..."

3. The Hospital's Accrediting Organization (AO) report of the Hospital's ligature risks, dated 7/26/18, was reviewed on 3/21/19 and included, "1) Observed in Building Tour ...In the 13K Behavioral Health Unit every patient bathroom door had a latching mechanism presenting a ligature risk ...In the 4K Behavioral Health Unit, every patient bathroom door had a latching mechanism presenting a ligature risk. The doors were also flush against the top of the frame ...In the 8 North Behavioral Health Unit, every patient bathroom door had a latching mechanism presenting a ligature risk ...The wardrobes in the rooms had doors on them presenting a ligature
risk ..."

4. On 3/21/19 between 9:45 AM and 10:40 AM, a tour of 8N (Adult Behavioral Health Unit) was conducted. There were 12 patient rooms on 8N (Rm 820 - Rm 831). Rooms 820 (2 beds), 821 (2 beds), 822 (1 bed), 823 (1 bed), 824 (2 bed), and 825 (2 bed) were blocked off entirely from the unit by a temporary wall for renovations, which were underway to remove the ligature risks in those patient rooms. Room #s 826-831 had not yet been renovated, and were available for use by patients. The patient rooms currently available for use were observed, and the following ligature risks were identified:

-All of the patient rooms (Rm 826 - Rm 831) contained the following ligature risks: Each entry door had 3 separate protruding hinges to the outside of the door. Bathroom door frames (one bathroom per room) were square and the doors reached to the top. Every bathroom contained a sink which protruded from the wall with open space under the sink, which could potentially allow the sink to be used for hanging by the patients on the unit. The beds, desks, and chairs in the rooms were not attached to the floor and could potentially be moved by the patients on the unit.
- Rm 826 contained a closet with a door that could not be locked. The closet had a square door frame, and the door reached to the top, which could be opened and used for hanging by the patients on the unit. The closet door also had 3 protruding hinges to the outside of the door, which could potentially be anchors for hanging by the patient.
- Rm 827 contained a closet with a door that could not be locked, which could be opened and used for hanging by the patients on the unit . The closet had a square door frame, and the door reached to the top (piano hinges were in place).
- Rm 828, Rm 829, Rm 830, and Rm 831 had wardrobes (freestanding closets with doors) in the rooms with square doors (tops of the doors were approximately 6 feet from the floor when opened) without locks, which could be opened and used for hanging by the patients on the unit.
- Rm 830 had a bathroom door with 3 separate protruding hinges to the outside of the door, which could potentially be anchors for hanging by the patientt.

5. On 3/21/19 from 11:00 AM - 11:55 AM, an observational tour of K13 (Adult Behavioral Health) was conducted. The unit consisted of 8 patient rooms (6 private rooms and 2 semi-private rooms). The ligature risks identified on K13 included solid, protruding sink faucets, which could potentially be anchors for hanging by the patient, in eight (8) patient bathrooms: 1302, 1308, 1309, 1310, 1311, 1312, 1313, and 1319.

6. On 3/20/19 at approximately 2:30 PM, an interview was conducted with the Assistant Vice President of Regulatory and Clinical Effectiveness (E #6). E #6 stated that the ligature risks on the behavioral health units were identified during an Accreditation Organization (AO) survey conducted in July 2018. E #6 stated that the Hospital immediately started a plan of correction which included renovations of the behavioral health units to eliminate the ligature risks. E #6 stated that the Hospital has been completing the renovations in phases, with a final completion date of June 2019.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for a patient who was admitted to the Hospital for suicide attempt and had access to a potentially hazardous item, the Hospital failed to ensure that rooms were checked and hazardous items were removed. This could potentially affect all patients at a high risk for suicide.

Findings include:

1. The Hospital's "Columbia Suicide Severity Rating Scale" procedure (undated) was reviewed on 3/21/19 and included, " ...Actions are required of you if the patient answers "yes" to a question ...Use largest number question with a "yes" answer to drive action of care ...Risk Level: High: #5, #6 ...If a patient answers "yes" to question 5: 1. Initiate a safety assistant; 2. Alert the physician; 3. Ask him or her to enter an order for: 1. Suicide risk 2. 1:1 monitoring ..."

2. The Hospital's policy titled, "Initiating a Safety Assistant" (approved by the Hospital on 9/25/18) was reviewed on 3/21/19 and included, " ... Required for patients with SI [suicidal ideation]/HI [homicidal ideation]: ...Check and clear room of prohibited/potentially hazardous items ..."

3. The Hospital's "SUICIDE/HOMICIDE SAFETY CHECKLIST" (undated) was reviewed on 3/21/19 and included, "PATIENT ROOMS: Check & clear dangerous items @ start of monitoring & every shift... STAFF to remove and/or properly secure potentially dangerous items..."

4. The clinical record for Pt #1 was reviewed on 3/20/19. Pt #1 was a 28 year old female who presented to the Hospital's emergency department (ED) on 3/14/19 at 6:21 PM with a complaint of feeling suicidal. The ED physician's note included, "Chief Complaint: Patient presents with Suicidal Thoughts ...suicidal ideation over the past few days, notes she feels like she is going [nowhere] with her life, and feels like she is [un]accomplished at age 28. Earlier today took a knife to her neck and attempted to harm herself. Notes she made a superficial injury to the right side of her neck, but denies any deep penetration of knife, minimal bleeding at the time..."

- The ED nurse's note, dated and timed 3/14/19 at 8:43 PM, included, " ... [Pt #1] Admits to putting a plastic bag on her head "to practice" on Monday. Today she stated she put a knife to her neck but stopped herself ..."

- The Columbia Suicide Scale was completed by the ED nurse at 8:44 PM and included that Pt #1 answered "yes" to questions #1 through #6, indicating that Pt #1 was a high risk for suicide.

- ED nursing notes indicated that Pt #1 was on 1:1 observation (for suicide precautions) with a Safety Assistant during Pt #1's entire time in the ED.

- Pt #1 was seen by a Psychiatry Resident (MD #3) in the ED. The psychiatrist's note, dated and timed 3/14/19 at 7:03 PM included, " ...presents with active suicide attempt this AM. Patient tried to slit her throat while at home with her roommate ...Denies prior suicide attempt ... Patient states that on Monday she practiced suicide via asphyxiation [depriving the supply of oxygen to the body] with a bag over her head. States that it took too long to work and switched to cutting her neck in an attempt to cut her carotid [artery in the neck]. States that she practiced with a plastic knife and when she was cutting today it took too much work to get through her skin ...Thought Content: Suicidal: active and with plan to cut neck ...Patient requires inpatient admission for escalation of care ...Patient is at imminent risk for further self-harm and cannot be managed at a lower level of care ...Treatment Plan: Patient to be admitted to the hospital. Reason for Admission to Psychiatric Unit: Threat to self requiring 24 hour professional observation ...Safety: 1:1 Sitter [constant visual observation of a patient; a safety assistant (SA) remains within immediate distance to the patient at all times] not indicated ..."

- The Psychiatry Resident's (MD #2) note, dated and timed 3/15/19 at 10:27 AM (Pt #1 still in the ED), included, " ...Thought content: Suicidal Ideation: Active ..."

- Pt #1 was admitted to the Hospital's adult behavioral health unit (8 North) on 3/15/19 at 11:43 AM.

- MD #2's admission orders, dated 3/15/19 at 10:27 AM, included, "Close Watch [observation with every 15 minute checks]."

- The nurse (E #4) completed the Columbia Suicide Scale on 3/15/19 at 12:13 PM, which included that Pt #1 answered "yes" to questions #1- #6, indicating that Pt #1 was a high risk for suicide. E #4's admission note, dated and timed 3/15/19 at 1:01 PM, included, " ...Initiate CO [close observation] every 15 minutes for safety ..."

- Nursing notes included the completion of a psychiatric daily observation on every shift while Pt #1 was awake. The observations on 3/15/19 at 12:16 PM (by E #4); 3/15/19 at 6:35 PM (by E #5); and 3/16/19 at 10:41 AM (by E #4) all included that Pt #1 answered "yes" to "Current Self Harm/Suicidal Ideation; Self Harm/Suicidal Ideation Plan; Previous Self Harm/Suicidal Ideation; and Previous Self Harm/Suicidal Ideation Plans."

- Nursing notes indicated that Pt #1 remained on Close Observation (every 15 minute checks) from 3/15/19 at 12:00 PM through 3/16/19 at 11:45 AM, instead of obtaining an order for 1:1 as required by policy, based on assessment of this patient.

- The nurse's (E #1) note, dated and timed 3/16/19 at 12:07 PM, included, "Upon entering patients room, to encourage patient to join music group at 11:15 [AM], [E #1] found patient sitting on washroom floor. Patient visible as door to washroom was wide open. [E #1] observed patient on floor with wet clothes (went into shower fully clothed). Moderate amount of blood noticeable on patients face, neck, towels. Upon further inspection, fresh blood found on shower and shower chair. Patient assessed and was found to have 2 puncture wounds on neck on each side. Staff called for assistance, pressure was placed on wounds with gauze. Patient appeared lethargic but conscious, when asked what happened, patient admitted to using black ball point pen. While other [nurse - E #4] tended to patient, [E #1] searched room and found pen patient used on top of desk ...MD paged regarding status, BP [blood pressure] at 1118 was BP 56/33 [normal range 90/60 - 120/80], HR [heart rate] 160 [normal range 60-100]. 911 called as treatment team was walking in. Patient conscious, talking and asking [MD #1] "how can I do it?" referring to another way of attempt. Paramedics arrived with security, patient cooperative. Was transferred to [a trauma hospital] at 1137."

5. The Environmental Safety Checklists (checks for contraband in all patient areas and rooms) from 3/15/19 and 3/16/19 were reviewed on 3/21/19 and included completion of the checklist at the change of every shift (day, evening, and night shifts), as required. The checklists documented that Pt #1's room (Rm 831) was free of clutter/contraband for every shift. However, Pt #1 was able to obtain a ballpoint pen to inflict self-injury while in her room.

6. On 3/21/19 at approximately 2:53 PM, an interview was conducted with E #1 (nurse who found Pt #1 in the shower on 3/16/19). E #1 stated that Pt #1 was assigned to a different nurse (E #4) on 3/16/19. E #1 stated that there was a group music session going on in the day room, and E #1 went to Pt #1's room to encourage Pt #1 to attend the session. E #1 stated that, when E #1 got to Pt #1's room, Pt #1 was not in bed. E #1 found Pt #1 sitting on the bathroom floor with blood on her neck and clothing. E #1 stated that MD #1 was contacted and immediately came to the unit. E #1 stated that Pt #1 was conscious and communicating appropriately until EMS (emergency medical services) arrived. E #1 stated that Pt #1 was on every 15 minute checks. E #1 stated that during report from the previous night shift, Pt #1's suicidal ideation in the ED and attempt to cut herself with a plastic knife at home were discussed. E #1 stated that they try to encourage patients to do their journaling in the milieu [common area of the unit] while they are using pens. E #1 stated that pens are kept at the nurses' station. E #1 stated that contraband checks are done at the change of every shift. Although pens are not considered contraband, E #1 stated that pens are collected and returned to the nurses' station if found in patient rooms during contraband checks. E #1 stated that any item that could be potentially hazardous for a patient at risk for suicide should be removed from the patient's room. E #1 stated that every patient area and room on the unit were searched for contraband following the incident with Pt #1, and no other contraband (or pens) were found in patient rooms.

7. On 3/20/19 at approximately 10:30 AM, an interview was conducted with the Vice President of Behavioral Health (E #2). E #2 stated that Pt #1 had a writing pen, and stabbed herself in the neck with it. E #2 stated that 8N was a higher functioning unit, and patients were allowed access to pens for journaling, crossword puzzles, etc.

C. Based on document review and interview, it was determined that for 2 of 4 (Pt #1 & Pt #3) clinical records reviewed for patients who were admitted to the Hospital for suicidal ideation, the Hospital failed to ensure that the appropriate level of patient safety monitoring was in place, in accordance with Hospital policy. This could potentially affect patients at a high risk for suicide.

Findings include:

1. The Hospital's "Columbia Suicide Severity Rating Scale" procedure (undated) was reviewed on 3/21/19 and included, " ...Actions are required of you if the patient answers "yes" to a question ...Use largest number question with a "yes" answer to drive action of care ...Risk Level: High: #5, #6 ...If a patient answers "yes" to question 5: 1. Initiate a safety assistant; 2. Alert the physician; 3. Ask him or her to enter an order for: 1. Suicide risk 2. 1:1 monitoring [constant visual observation of a patient; a safety assistant (SA) remains within immediate distance to the patient at all times] ..."

2. The Hospital's policy titled, "Initiating a Safety Assistant" (approved by the Hospital on 9/25/18) was reviewed on 3/21/19 and included, " ...The use of a Safety Assistant is required for suicidal behavior ...The use of a Safety Assistant is initiated and discontinued by the Registered Nurse ...Required for patients with SI [suicidal ideation]/HI [homicidal ideation]: ...Check and clear room of prohibited/potentially hazardous items ..."

3. The Hospital's policy titled, "Patient Safety Monitoring" (approved by the Hospital on 5/25/18) was reviewed on 3/21/19 and included, " ...All patients admitted to inpatient psychiatry will be placed on Close Watch [every 15 minute checks], Close Watch with Modifications [constant visual observation of the patient; within line of sight of staff], or 1:1 [constant visual observation of a patient; a safety assistant (SA) remains within immediate distance to the patient at all times] observation on admission ...nursing may increase level of monitoring without an order ...RN: Obtain an order for the appropriate level of monitoring ...Assess patient's status daily ...to determine the appropriate level of monitoring ..."

4. The clinical record for Pt #1 was reviewed on 3/20/19. Pt #1 was a 28 year old female who presented to the Hospital's emergency department (ED) on 3/14/19 at 6:21 PM with a complaint of feeling suicidal. The ED physician's note included, "Chief Complaint: Patient presents with Suicidal Thoughts ... suicidal ideation over the past few days, notes she feels like she is going [nowhere] with her life, and feels like she is [un]accomplished at age 28. Earlier today took a knife to her neck and attempted to harm herself. Notes she made a superficial injury to the right side of her neck, but denies any deep penetration of knife, minimal bleeding at the time..."

- The ED nurse's note, dated and timed 3/14/19 at 8:43 PM, included, " ... Admits to putting a plastic bag on her head "to practice" on Monday. Today she stated she put a knife to her neck but stopped herself ..."

- The Columbia Suicide Scale (suicide risk assessment tool) was completed by the ED nurse at 8:44 PM and included that Pt #1 answered "yes" to questions #1 through #6, indicating that Pt #1 was a high risk for suicide.

- ED nursing notes indicated that Pt #1 was on 1:1 observation (for suicide precautions) with a Safety Assistant during Pt #1's entire time in the ED.

- Pt #1 was seen by a Psychiatry Resident (MD #3) in the ED. The psychiatrist's note, dated and timed 3/14/19 at 7:03 PM included, " ...presents with active suicide attempt this AM. Patient tried to slit her throat while at home with her roommate ... Patient states that on Monday she practiced suicide via asphyxiation [deprive the body of oxygen] with a bag over her head. States that it took too long to work and switched to cutting her neck in an attempt to cut her carotid [artery in the neck]. States that she practiced with a plastic knife and when she was cutting today it took too much work to get through her skin ...Thought Content: Suicidal: active and with plan to cut neck ...Patient requires inpatient admission for escalation of care ...Patient is at imminent risk for further self-harm and cannot be managed at a lower level of care ...Treatment Plan: Patient to be admitted to the hospital. Reason for Admission to Psychiatric Unit: Threat to self requiring 24 hour professional observation ...Safety: 1:1 Sitter not indicated ..."

- Pt #1 was admitted to the Hospital's adult behavioral health unit (8N) on 3/15/19 at 11:43 AM. MD #2's admission orders, dated 3/15/19 at 10:27 AM, included, "Close Watch [observation with every 15 minute checks]."

- The 8N nurse (E #4) completed the Columbia Suicide Scale on 3/15/19 at 12:13 PM (admission assessment), which included that Pt #1 answered "yes" to questions #1- #6, indicating that Pt #1 was a high risk for suicide. E #4's admission note, dated and timed 3/15/19 at 1:01 PM, included, " ...Initiate CO [close observation] every 15 minutes for safety ..." 1:1 monitoring for suicide risk was not initiated at this time, based on the Columbia Suicide Scale, in accordance with Hospital policy.

- Nursing notes included the completion of a psychiatric daily observation on every shift while Pt #1 was awake. The observations on 3/15/19 at 12:16 PM (by E #4); 3/15/19 at 6:35 PM (by E #5); and 3/16/19 at 10:41 AM (by E #4) all included that Pt #1 answered "yes" to "Current Self Harm/Suicidal Ideation; Self Harm/Suicidal Ideation Plan; Previous Self Harm/Suicidal Ideation; and Previous Self Harm/Suicidal Ideation Plans." However, no 1:1 monitoring or increased level of monitoring was initiated in response to these assessments.

- The nurse's (E #1) note, dated and timed 3/16/19 at 12:07 PM, included, "Upon entering patients room, to encourage patient to join music group at 11:15, [E #1] found patient sitting on washroom floor. Patient visible as door to washroom was wide open. [E #1] observed patient on floor with wet clothes (went into shower fully clothed). Moderate amount of blood noticeable on patients face, neck, towels. Upon further inspection, fresh blood found on shower and shower chair. Patient assessed and was found to have 2 puncture wounds on neck on each side. Staff called for assistance, pressure was placed on wounds with gauze. Patient appeared lethargic but conscious, when asked what happened, patient admitted to using black ball point pen. While other RN tended to patient, [E #1] searched room and found pen patient used on top of desk ...MD paged regarding status, BP [blood pressure] at 1118 was BP 56/33 [normal range 90/60 - 120/80], HR [heart rate] 160 [normal range 60-100]. 911 called as treatment team was walking in. Patient conscious, talking and asking [MD #1] "how can I do it?" referring to another way of attempt. Paramedics arrived with security, patient cooperative. Was transferred to [a trauma hospital] at 1137 [11:37 AM]."

5. On 3/21/19 at approximately 10:40 AM, an interview was conducted with MD #1 (Attending Psychiatrist/Director of Psychiatry/Signed off on Psychiatry Residents' notes). MD #1 stated that Pt #1 presented to the ED around 6:00 PM on 3/14/19 depressed, with suicidal ideation. MD #1 stated that Pt #1 had practiced suicide methods like asphyxiation and cutting neck with a plastic knife, resulting in a superficial scratch to her neck. MD #1 stated that Pt #1 was appropriate for inpatient treatment. MD #1 stated that Pt #1 was seen in the ED by the Psychiatric Resident who determined that Pt #1 did not need 1:1 observation because Pt #1 had no active suicidal plan while admitted. Therefore, the Resident ordered every 15 minute checks for Pt #1. MD #1 stated that Pt #1 was seen by another Psychiatric Resident on 8N, and Pt #1 did not give any indication of an active suicidal plan. MD #1 stated that Pt #1 was fine through the night on 3/15/19. MD #1 stated that although Pt #1's outcome was unfortunate, Pt #1's voluntary admission which indicated that she wanted to be in the Hospital; every 15 minute checks; interacting appropriately; no agitation; first hospitalization; and no behavioral cues to heighten concerns did not indicate that Pt #1 required 1:1 observation.

6. On 3/25/19 at approximately 9:30 AM, an interview was conducted with E #4 (Nurse who admitted Pt #1 on 3/15/19 and was assigned to the care of Pt #1 on 3/15/19). E #4 stated that Pt #1 stated that she had been feeling suicidal within the last month, but had no active suicidal plan on admission. E #4 stated that Pt #1's behavior did not indicate the need for a higher level of observation. E #4 stated that Pt #1 was cooperative throughout admission; asked questions about group scheduling; expressed interest in Alcoholics Anonymous meetings; interacted appropriately with peers in the milieu (common open area); and made a phone call to her mother. E #4 stated that the patients are encouraged to journal, and it's appropriate for patients to have pens in their rooms for this. E #4 stated that a high risk suicide score on the Columbia Suicide Severity Rating Scale does not necessarily require the patient to be placed on 1:1 observation. E #4 stated that, since Pt #1 did not have an active suicidal plan after admission, CO with 15 minute checks was the appropriate observation level for Pt #1.

7. The clinical record for Pt #3 was reviewed on 3/21/19. Pt #3 was a 13 year old female who was admitted to the K4 (Child and Adolescent Behavioral Health Unit) on 3/18/19 at 8:50 PM for suicidal ideation with a plan to cut herself. E #9's (Psychiatric Nurse Practitioner) admitting orders included Pt #3's precautions were close observation and self injury (requiring every 15 minute checks). The 4K nurse (E #10) completed the Columbia Suicide Scale on 3/18/19 at 9:42 PM (admission assessment), which included that Pt #3 answered "yes" to questions #1-#6, indicating that Pt #3 was a high risk for suicide. 1:1 monitoring for suicide risk was not initiated at this time, based on the Columbia Suicide Scale, in accordance with Hospital policy.

8. On 3/21/19 at approximately 11:30 AM, an interview was conducted with E #11 (Assistant K4 Unit Director). E #11 stated that Pt #3 was on close watch and self injury precautions with every 15 minute checks. E #11 stated that Pt #3 was not suicidal but had thoughts of self injury, like cutting herself. E #11 stated that 1:1 observation was not indicated for Pt #3.

9. On 3/25/19 at approximately 9:45 AM, an interview was conducted with the Vice President of Behavioral Health (E #2). E #2 stated that the Columbia Suicide Severity Rating Scale is not a policy, but a procedure that is used hospital-wide. E #2 stated that 1:1 observation would be indicated for a patient who scored a high risk for suicide on a medical unit of the hospital. E #2 stated that once a patient is admitted to a behavioral health unit (BHU), the observation level is determined based on the assessment and clinical judgment of the psychiatrists and the nurses. Therefore, patients on the BHUs are not automatically placed on 1:1 observation based on the Columbia Suicide Severity Rating Scale.