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Based on observation, interview, record review and policy review, the facility failed to ensure that patients were safe when bed power cords that measured 26.5 inches (unit of measurement) in length, a potential ligature (material use to tie or bind, a potential for hanging or suffocation) risk, weren't shortened or secured for 12 of 12 beds on the Adult Medical Behavioral Health Unit (BHU). The facility also failed to ensure that one current patient's oxygen tubing (#28) of one patient with oxygen tubing that measured approximately five to six feet (unit of measurement) in length, was not accessible to suicidal patients for potential use as a ligature. Eight of 12 patients on the medical BHU were on suicide precautions.

These failures created an unsafe environment and had the potential to place all suicidal patients admitted to the facility at risk for their safety. The facility census was 640 and the BHU census was 61.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights, that resulted in a condition of Immediate Jeopardy (IJ).

As of 11/30/17, at the time of survey exit, the facility provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:
- Immediate Action: The Maintenance coworkers physically modified the bed power cord to shorten the length of exposed cord to 18 inches.
- 100% of the medical beds used for psychiatric patients, were visually inspected to ensure all beds that had power cords were shortened.
- All patients admitted to inpatient behavioral health that required medical equipment posing as a ligature risk, including but not limited to Intravenous (IV, within the vein) tubing, Continuous Positive Air Pressure (CPAP, machine that applies mild air pressure to keep the airways open, used for sleep apnea), or Oxygen, will remain within Staff View. All current patients have been reassessed for level of suicide (intentionally causing one's own death) precautions and potential for ligature risk with medical equipment.
- Immediate education to coworkers regarding policy creation that required all patients admitted to inpatient behavioral health on medical equipment posing as a ligature risk will have a provider order for the patient to remain in view of coworkers. 100% coworker education would be completed prior to next shift.
-Education on the facility policy for management of patients with medical equipment will be provided face to face prior to shift and included the requirement for a physician order.
- The Director of Nursing for BHU will ensure daily auditing will be performed for all patients with medical equipment to confirm patients' orders of precaution level monitoring is either in view of staff (constant view of patient by staff) or one-to-one (1:1, one staff member assigned to observe and stay with one patient at all times) and matches the current physician order. This audit will be performed daily for two months and if at 100% compliance and then twice weekly for three months until compliance is reached.
- Real-time monitoring of all patients with medical equipment in the BHU will be performed every four hours by unit leadership or quality management until revisit. The every four hour check will confirm appropriate precautions (either Staff View or 1:1) are in place. As per hospital policy called Patient Placement and Throughput, patients on suicide precautions are not admitted to medical/surgical units.
- The physician determines the level of monitoring which may include at a minimum varied 15 minute monitoring, Staff View or 1:1 observations.
- Immediate action: 100% coworker education on expectation of rounding sheet prior to next shift will be completed.
- The Assistant Director of Nursing - BHU, will ensure daily auditing will be performed on rounding sheet documentation. This audit will be performed daily for two months and then twice weekly for three months until compliance is reached.
- Real-time monitoring of the rounding sheet documentation in the BHU will be performed every four hours by unit leadership or quality management until revisit.
- The every four hour check will confirm that the patient precautions and level of monitoring are on the rounding sheets.
- Immediate Action: Implementation of a shift census report sheet for ongoing shift to review and initial.
- 100% coworker education prior to next shift will be completed.
- Census sheet will list all precautions for every behavioral health patient in the unit for the oncoming supervisor to pick up the report at the start of the shift.
- Behavioral Health Tech/Patient Care Associate and Registered Nurse report sheet will be completed each shift.

Based on observation, interview and record review, the facility failed to ensure that they provided privacy for two current Adult Medical Behavioral Health Unit (BHU) patients (#3 and #23) of 12 current patients who were made to sleep in the hallways of the BHU, visible to other patients and staff, which prevented privacy, adequate rest, relaxation and sleep. This had the potential to affect all patients who were admitted to the BHU by preventing them from having personal privacy to rest and sleep. The facility census was 640. The BHU census was 61.

Findings included:

1. Although requested, the facility failed to provide a policy related to patient privacy.

Record review of the facility's brochure titled, "Patient Rights and Responsibilities," dated 08/18/16, showed that patients have a right to quality health care that includes dignity and respect for their cultural, physical, psychosocial, spiritual, educational, personal values, beliefs and preferences.

Record review of the facility's policy titled, "Patient Observation Rounds," dated 05/31/17 showed that "within Staff View" indicated:
- Patients who are assessed to be at heightened risk of harm to self or others per clinical judgement, and who are cooperative in remaining in the common areas of the unit and within view of staff.
- Patients are continuously monitored within line of sight of staff.
- The nurse caring for the patient is responsible for ensuring patient is in line of sight of staff.

2. Observation on 11/28/17 at 2:15 PM on the Adult Medical BHU showed Patient #3 asleep on a hospital bed that was positioned in the hallway directly in front of the nursing station.

During an interview on 11/28/17 at 2:30 PM, Staff C, Clinical Nursing Supervisor for Adult Medical BHU, stated that Patient #3 liked to nap during the day, and that patients who were on "Staff View" slept at the nursing station or in the group room so "staff could see them."

During an interview on 11/29/17 at 10:30 AM, Staff CC, Director of Nursing (DON) for BHU stated that if a patient was on "Staff View" it meant that the patient was in view of staff when they were sleeping and awake. She stated that if a patient was on Staff View that a PCT would be in the room for line of sight but if there were only a couple of patients on Staff View then their beds were placed in the hallway for "easy view and to also help on staffing."

3. Observation on 11/29/17 at 8:45 AM, showed two electric hospital beds in the hallway on the BHU. One bed was in the same location (in front of the nurses' desk) as it was observed the day prior. The second bed was located at the end of the hallway. Both beds had wrinkled sheets and were pulled down towards the bottom of the bed and appeared to have been slept in.

During an interview on 11/29/17 at 9:55 AM, Staff PP, Patient Care Technician (PCT), stated that when she arrived to work this morning at 6:30 AM, both Patient #3 and #23 were sleeping on their beds in the hallway. She stated that they slept in the hallway because they were on Staff View.

During an interview on 11/30/17 at 8:55 AM, Patient #3 stated that staff put her in the hallway and she had slept there every night since admission. She stated that she would rather sleep in her room.

During an interview on 11/29/17 at 9:00 AM, Patient #23 stated that his bed was moved from his room into the hallway because he "got mad."

4. During an interview on 11/29/17 at 9:30 AM, Staff OO, Registered Nurse, (RN) stated that Patient #23's bed was in the hallway so staff could keep him in their line of sight. He stated that Patient #23 had sexual acting out (SAO) behavior and this resulted in the line of sight precaution.

During an interview on 11/29/17 at 10:30 AM, Staff GG, RN Pediatric/Adolescent BHU, stated that if a patient was on Sexually Acting Out (SAO, inappropriate touching, kissing, making suggestive remarks or being secretive in pursuit of sexual encounters) precautions, the patient would be in Staff View and their mattress would be placed in the doorway during times of rest during the day and at bedtime.

During an interview on 11/29/17 at 11:45 AM, Staff LL, RN Pediatric/Adolescent BHU, stated that if a patient was on SAO precautions the patient would remain in Staff View at all times and would be placed in a private room if available. She stated that if a private room was not available the patient's mattress would be placed in the annex (additional space) of the quiet room or in the doorway of their room.

During an interview on 11/29/17 at 9:30 AM, Staff C, DON BHU, stated that any patient with SAO precautions would always be in Staff View and automatically have to "sleep-out" which meant that they would either be in a private room if available with 1:1 monitoring if necessary, have their mattress placed in the annex of the quiet room or in the doorway of their room or in the hallway.

The facility failed to provide privacy and dignity for patients who were on the observation level of "Within Staff View", when facility staff placed their beds in the hallways or in the common areas of both the Adult Medical and the Pediatric/Adolescent BHU, so that those patients remained within line of sight of staff at all times.


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Based on observation, interview, record review and policy review, the facility failed to ensure:
- Patients were safe when bed power cords that measured 26.5 inches (unit of measurement) in length, a potential ligature (material used to tie or bind, a potential for hanging or suffocation), weren't shortened or secured for 12 of 12 beds on the Adult Medical Behavioral Health Unit (BHU);
- Oxygen tubing for one current patient (#28) of one patient with oxygen tubing, that measured approximately five to six feet (unit of measurement) in length, was not accessible to suicidal patients on the Adult Medical BHU; and
- Staff followed facility policy for one current patient (#1) of two current patients on Sexual Acting Out (SAO, inappropriate touching, kissing, making suggestive remarks or being secretive in pursuit of sexual encounters) precautions when Patient #1, who was to be observed by staff at all times, was unattended in the dining room on the Adult Medical BHU.
The bed power cords and oxygen tubing were potential ligature (material use to tie or bind, a potential for hanging or suffocation) risk, and placed all patients at risk for self-harm or injury. Eight of 12 patients on the Adult Medical BHU were on suicide precautions. The facility census was 640. The BHU census was 61.

Findings included:

1. Record review of the facility's policy titled, "Suicide Precautions," dated 05/2017 showed that a safe and secure environment would be provided for patients who have been assessed to be suicidal or at risk of harm to self.

Observation on 11/28/17 at 2:05 PM on the Adult Medical BHU showed patient beds with power cords. The exposed cord measured 26.5 inches from tip of the plug to underneath the bed. The cord measured 18 inches from the tip of the plug to the edge of the bed with an additional exposed cord that measured seven inches from the edge of the bed to underneath the bed to where the cord went inside a metal conduit (a tube or trough for protecting electric wiring).

During an interview on 11/28/17 at 2:30 PM Staff C, Clinical Nursing Supervisor, stated that the patients admitted to this unit had comorbidities (the presence of two diseases, disorder or illness that occurs at the same time) so they required electric (corded) medical beds.

During an interview on 11/29/17 at 3:15 PM, Staff BB, Executive Director for BHU, verified the 26.5 inch cord measurement and stated that the beds were supposed to have 18 inches of cord for patient safety, per the company the beds were ordered from.

The length of these cords created an unsafe environment for psychiatric patients with the potential for suicidal patients to use the cords as a ligature.

2. Record review of the facility's policy titled, "Patient Observation Rounds," dated 05/31/17 showed the following:
- Purpose was to ensure appropriate monitoring of patients in the psychiatric hospital setting.
- One to One (1:1, one staff member assigned to observe one patient at all times): Patients, who are assessed to be at heightened risk of suicide, self-harm to other.
- Within Staff View (patient must remain within view of one or more staff members at all times): Patients who are assessed to be at heightened risk of harm to self or others per clinical judgment, who are cooperative in remaining in the common areas of the unit and within view of staff. Patients are continuously monitored within line of sight of staff. The nurse caring for the patient is responsible for ensuring a patient is in line of sight of staff.

Record review of Patient #28's History and Physical (H&P) by Staff QQ, Physician, showed the following:
- She was admitted on 11/24/17 with drug abuse and a three week history of suicidal ideations (SI), with a plan to overdose;
- Past medical history of Chronic Obstructive Pulmonary Disease (COPD, lung disease with chronic obstruction of lung airflow that interferes with normal breathing); and
- Plan was to admit to psychiatric ward (BHU) with close observations for suicidal behaviors.

Observation on 11/29/17 at 8:45 AM showed Patient #28 standing at the nursing station with approximately five to six feet of flexible oxygen tubing that extended across the hallway from the patient's room.

During an interview on 11/29/17 at 10:00 AM, Patient #28 stated that when she slept in her room at night, staff did not stay in the room to monitor her.

During an interview on 11/29/17 at 9:10 AM, Patient #27 stated that she was Patient #28's roommate and verified that she and Patient #28 slept in the same room without continuous staff observation.

During an interview on 11/30/17 at 10:00 AM, Staff QQ, Physician, stated oxygen tubing "was always a potential (ligature risk) for other patients who were at risk."

This showed that Patient #28 was at risk for self-harm due to the length of oxygen tubing, and placed other patients at risk for self-harm or potential harm to others.

3. During an interview on 11/29/17 at 10:20 AM Staff C, Clinical Nursing Supervisor, stated that Patient #3 was the only current patient on Staff View precautions.

Observation and subsequent interview on 11/29/17 at 8:55 AM showed Patient #3 exited her room, unattended by staff, and walked down the hallway.

Observation on 11/29/17 at 8:48 AM showed an electric hospital bed located in the hallway. The power cord to the electric bed measured 26.5 inches from tip of the plug to underneath the bed (ligature risk).

During an interview on 11/29/17 at 10:05 AM Staff CC, Director of Nursing for BHU, stated that Patient #3, during her previous admission (10/2017), had taken another patient's oxygen tubing and put it around her neck.

During an interview on 11/29/17 at 9:10 AM, Patient #27 stated that Patient #3 had ripped the hallway phone from her (Patient #27) hand, and wrapped the phone cord around her (Patient #3) neck.

Patient #3 was at high risk for ligature strangulation based on recent and current admission behaviors. The patient was left unattended by staff in her room and in the hallway. The patient had access to electric (corded) beds placed in the hallway, and five to six feet of oxygen tubing worn by another patient, which placed the patient in an unsafe environment that was high risk for self-harm.

4. Record review of Patient Daily Safety Rounds dated 11/28/17 for eight current patients (#1, #3, #4, #20, #22, #25, #26, and #28) showed that they were on suicide precautions.

The Adult Medical BHU had 12 electric (corded) beds and one patient (#28) with oxygen tubing. Patient #28 was not on Staff View and there were eight patients on suicide precautions. The patients were at risk for their safety with the accessibility to the bed power cords and oxygen tubing that were potential hanging mechanisms.

5. Record review of the facility's policy titled, "Sexual Acting Out Precautions," revised 10/2017, showed the patient on sexually acting out precautions is placed in Staff View until the physician deems another level of observation rounding is appropriate.

Observation and subsequent interview on 11/29/17 at 10:25 AM showed Patient #1 seated at a table eating breakfast in the dining room unattended. No staff members were in the dining room with Patient #1. The dining room was not visible to staff from the hallway. Patient #1 was not within staff view and placed other patients at risk for their safety.

Record review of Patient #1's Patient Daily Safety Round sheet dated 11/29/17 showed the patient on fall, suicide and sexual acting out precautions.

Per facility policy Patient #1 should have been on staff view with his sexual acting out precaution.

Based on interview, record review, policy review, review of the facility's Rules and Regulations, and review of the Revised Statutes for Missouri (RSMO), the facility failed to ensure restraints were ordered only by a physician, when the facility allowed Nurse Practitioners (NP) to order non-violent restraints in the Intensive Care Units (ICU) for three patients (#36, #38, and #40) of five patient records reviewed. This failure had the potential to cause poor nursing care outcomes for restrained patients. The facility census was 640. There were 41 patients in non-violent restraints.

Findings included:

1. Record review of the facility policy titled, "Restraints, Seclusion, Protective/Assistive Devices" revised and reviewed 03/2017 showed the following:
- Credentialed Provider orders are required for each episode of non-violent and violent restraint or seclusion.
- A Physicians's Assistant in Missouri may not order restraints.
- Each episode of restraint use must be initiated in accordance with the order of the provider.
- A Credentialed Provider can authorize the use and continued use of non-violent restraints.

Record review of the facility Rules and Regulations, "Prerogatives of Allied Health Professionals (AHP, includes NP)," performed such services as granted as privileges, and consistent with any limitations stated in the policies governing the AHP's practice in the hospital and any other applicable government regulations, medical staff and hospital policies.

Record review of RSMO 630.175 showed that an NP who is in a collaborative practice with a physician, can write restraint orders only for behavioral health patients.

Record review of the Delineation of Privileges provided by the facility for Staff SS, NP, and Staff ZZ, NP, did not specify that they could write orders for non-violent restraints.

2. Record review of orders for Patient #36 showed a non-violent restraint order, dated 11/23/17 at 9:33 AM, written by Staff SS, NP.

Record review of orders for Patient #38 showed a non-violent restraint order dated 11/25/17 at 2:03 PM and 11/26/17 at 10:50 AM, written by Staff SS, NP.

Record review of orders for Patient #38 showed a non-violent restraint order, dated 11/28/17 at 11:18 AM, written by Staff ZZ, NP.

Record review of RSMO 630.175 showed that an NP who is in a collaborative practice with a physician, can write restraint orders only for behavioral health patients.

Record review of the Delineation of Privileges provided by the facility for Staff SS, NP, and Staff ZZ, NP, did not specify that they could write orders for non-violent restraints.

3. During an interview on 11/30/17 at 11:30 AM, Staff SS, NP, stated that she only practiced in the ICU and that she probably wrote five non-violent restraint orders daily. She stated that she could write orders as a Credentialed Provider. She stated that she did not know if her orders needed to be co-signed by a physician.

During the exit on 11/30/17 at 3:45 PM Staff BBB, Chief Quality Officer (CQO) stated that NPs were authorized to write restraint orders.