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Based on observation, staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure that patients at risk for self-harm are kept safe.

Findings include:

1. The facility failed to ensure that patients on line-of-sight (LOS) observation are continuously observed while in the bathroom. (Cross Refer to Tag-0144)

2. The facility failed to ensure that staff are re-educated on the facility's policy for LOS and 1:1 (one-to-one) observation after a patient on 1:1 observation successfully harmed him/herself. (Cross Refer to Tag-0144)

3. The facility failed to ensure that patients, families, and visitors are educated regarding safety practices for patients on LOS and 1:1 observation, in accordance with the facility policy and procedure. (Cross Refer to Tag-0144)

4. The facility failed to ensure that environmental rounds are completed accurately by staff for patients on LOS or 1:1 observation. (Cross Refer to Tag-0144)

Based on observation, staff interview, review of the medical record of Patient #1 (P1), and review of facility documents, it was determined the facility failed to ensure that: 1) staff maintain continuous visual observation of patients on line of sight (LOS) observation while patients are in a bathroom with ligature risks; 2) staff re-education is conducted on roles and responsibilities of performing one-to-one (1:1) observation and LOS observation after a patient on 1:1 observation successfully harmed him/herself; 3) the patient, family, and visitors are educated regarding safety practices for patients on LOS and 1:1 observation, in accordance with facility policy and procedure; 4) staff remove safety risks for patients at risk of self-harm when conducting environmental rounds.

Findings include:

1) Reference: Facility policy titled, "Patient Watch for Behavioral Indications (last revised 10/2022) states, " ... 1. One to One Observation: requires that a patient be visually observed by a staff member who remains with the patient at all times. ... 2. Line of Sight: is defined as a staff member observing a maximum of 2 patients, all of whom are within the same physical space and/or room within the same visual field at all times. ... Staff should be at an arm's length apart from the patient when performing a one to one observation unless there is a Physician order stating otherwise."

Review of P1's medical record on 04/03/23 at 11:00 AM, in the presence of Staff #1 and Staff #2, revealed the following:

P1 was admitted to the Emergency Department (ED) on 03/24/23 at 4:52 PM with a chief complaint of a "Psych (psychiatric) Eval." A physician evaluation was documented at 4:52 PM. At 4:59 PM, a triage note containing a Columbia Suicide Severity Rating Scale (CSSR) indicated that P1 was identified as being high risk for suicide. Physician orders were entered for LOS observation at 6:02 PM, and then for 1:1 observation at 7:05 PM. A review of the "Patient Watch Observation" forms indicate a sitter was present with P1 on arrival to the ED at 4:45 PM, and remained with the patient when he/she was transferred to 2N Annex on 03/24/23 at 11:00 PM. On 03/25/23 at 1:38 PM, a psychiatric evaluation was conducted and P1 was removed from 1:1 observation and placed on LOS observation.

A Nurse Progress note dated 03/26/23 at 10:14 AM stated, "Pt (patient) on Line of Sight. According to [name of staff], pt got up to use the bathroom with door closed. Nurse aide went to check on pt and found bathroom door was closed. When knocked on the door, there was no response from pt but heard a smashing noise. Nurse [name of nurse] passing by room, heard smashing noise as well and called primary nurse [name of nurse] to the room. Upon entering the room, found nurse aide knocking and calling pt's name but door remained locked. Primary nurse [name of nurse] also called out pt's name, no response. Used a quarter to unlock door and found pt sitting on toilet with broken glass in hand slitting left wrist, crying ... Removed broken glass from pt's hand while nurse [name of nurse] applied pressure to wound laceration horizontally. RRT (rapid response team) was called ... Skin assessment was done ... Dr. [name of doctor] was called and informed of situation and gave order for patient watch 1:1... ."

During an interview on 04/03/23 at 10:24 AM, Staff #1 (Assistant Vice President, Regulatory) confirmed that P1 was able to go into a bathroom and lock the door, while on LOS observation and cut his/her wrist with a glass bottle. Staff #1 stated Staff #24 (Nurse's Aide performing LOS observation for P1 on 03/26/23) stated he/she "was not aware that line of sight meant to continuously keep an eye on the patient."

At 10:57 AM, Staff #1 stated that all sitters are educated on how to perform 1:1 and LOS observation during orientation and are re-educated annually. Staff #1 stated that environmental checks are supposed to be completed by staff performing the 1:1 or LOS observation, and that continuous observation should be maintained for all patients on LOS observation, including when the patients go in the bathroom. Upon interview, Staff #1 stated he/she was unable to determine why Staff #24 was unaware that he/she was expected to go into the bathroom with P1. Review of Staff #24's personnel file revealed he/she received annual education regarding the performance of 1:1 and LOS observation.

A review of the incident report dated 03/26/23, in the presence of Staff #1 and Staff #2 (Director of Business Analytics), was conducted on 04/03/23 at 10:35 AM. The incident report stated that the "individual" and "system" failed because "[Staff #24] was not aware that line of sight meant to continuously keep an eye on the patient."

A tour of 2N Annex was conducted on 04/03/23 at 12:04 PM, in the presence of Staff #1. The unit is a 26 bed unit with a patient census of 23. A tour of P1's assigned room was conducted. Observation of the bathroom revealed numerous ligature and safety risks which included: a grab bar, four knobs on the wall with a detachable hose approximately two feet long, and a toilet with exposed piping. Upon interview, Staff #1 and Staff #2 confirmed that if the bathroom door is locked, staff do not have a tool available to immediately unlock the bathroom door. Staff #1 and Staff #2 stated that a person's finger nail or a flat item can possibly be used to open the door. Staff #1 stated this is why a quarter was used to unlock the bathroom door during the incident that occurred on 03/26/23.

2) Review of P1's medical record on 04/03/23 at 11:00 AM, in the presence of Staff #1 and Staff #2, revealed two incidences of P1 committing or attempting self-harm while under staff observation on unit 2N Annex.

On 03/26/23 at 10:14 AM, a nurse documented that while on LOS observation, P1 was able to go into a bathroom containing ligature and safety risks, lock the door, and use a glass bottle found in the bathroom to cut his/her wrist. P1 sustained an injury to his/her wrist which needed stitches. P1 was then placed on a 1:1 observation.

On 03/27/23 at 8:25 PM, documentation in the medical record indicated that P1 was able to obtain a screen protector from a cell phone, break it, and attempt to cut his/her wrist, while on 1:1 observation. Staff #1 indicated that the cell phone belonged to the patient's mother, who was visiting the patient. When asked how the patient was able to obtain the cell phone screen protector, Staff #1 stated, "We don't know." On 03/27/23 at 11:52 PM, P1 was medically cleared and was moved to an inpatient behavioral health unit on 03/28/23 at 12:30 AM.

During an interview on 04/03/23 at 10:57 AM, Staff #1 stated that the investigation of the incident involving P1 that occurred on 03/26/23 and 03/27/23 were still ongoing and being conducted by the Nursing Supervisor of 2N Annex. Staff #1 stated that all staff are educated during orientation about keeping bathroom doors open while patients on 1:1 or LOS observation are toileting. Staff #1 stated that due to the ongoing investigation, since the events occurred, the facility "found no opportunities" to re-educate staff on any policies and procedures. Staff #1 was asked if Staff #24 was re-educated on maintaining continuous observation of patients on LOS observation, even when they go in the bathroom. Staff #1 confirmed that no re-education was provided to Staff #24. A request was made to Staff #1 to interview the Nurse Manager of 2N Annex. Staff #1 stated he/she was not available.

On 04/03/23 at 12:05 PM, a tour of 2N Annex was conducted. At 12:15 PM, an interview was conducted with Staff #4 (Interim Nurse Manager of 2N Annex). Staff #4 stated he/she was informed of the incidents that occurred on the unit and stated he/she believed the nurse manager spoke with the staff afterwards during a "huddle." Upon request, the facility was unable to provide any documentation or confirmation of a staff meeting or re-education.

During a tour of unit 2N Annex on 04/03/23 at 12:04 PM, interviews were conducted with Staff #3 and Staff #22 (Registered Nurses). Staff #3 and Staff #22 both stated they had not received any re-education regarding the facility's policy and procedure on performing 1:1 or LOS observation.

During a telephone interview conducted on 04/04/23 at 12:33 PM, Staff #26 (Nurse's Aid) stated that he/she did not receive re-education regarding the facility's policy and procedure on performing 1:1 or LOS observation.

3) Reference: Facility policy titled, "Suicide Risk Screening for Non-Behavioral Units" dated 10/21, stated, " ... Risk Level- HIGH RISK ... Interventions ... Educate patient/family regarding safety practices ... ."

On 04/04/23 at 10:25 AM, an interview was conducted with Staff #6 (RN), who was the RN assigned to P1 on 03/26/23 during his/her attempt at self harm. Staff #6 stated that he/she does not know how the patient received a glass bottle, but believes a family member brought in the item. Staff #6 stated that he/she was aware that education of the family is to be conducted for patients on LOS or 1:1 observation regarding contraband and bringing outside items into the patient's room, however, he/she did not educate the family on contraband or safety practices because it was a "tricky situation." Staff #6 stated, "I couldn't really explain to the family not to bring in anything because the patient requested that no information be shared with the family."

During an interview on 04/03/23 at 1:00 PM, Staff #1 stated that the 1:1 sitter is expected to educate family and visitors about not bringing in contraband items when they are visiting a patient on LOS or 1:1 observation. A review of the medical record showed no evidence that education was provided to family or visitors for P1 regarding safety practices. Staff #1 and Staff #2 confirmed during medical record review, that there was no evidence that education was provided to the family or visitors regarding not bringing in contraband items. During a review of facility policy titled, "Suicide Risk Screening for Non-Behavioral Units," Staff #1 and Staff #2 confirmed that the policy does not indicate which staff is responsible for educating the family about not bringing in contraband items for patients on LOS and 1:1 observation. Staff #1 and Staff #2 confirmed that there is no required documentation in the medical record to verify that education regarding contraband items was provided to family and visitors.

4) On 04/03/23 at 10:57 AM, Staff #1 and Staff #2 stated that the nurse or staff performing 1:1 or LOS observation are required to perform daily environmental rounds of the patient's room. At 11:00 AM, a facility policy regarding performing environmental rounds for patients on 1:1 or LOS observation was requested. The facility was unable to provide a policy or procedure regarding environmental rounds.

On 4/03/23 at 11:45 AM, the "1:1/LOS Checklist" for 03/26/23 was reviewed. The "1:1/LOS Checklist" included documentation for performing environmental rounds.

On 04/04/23, the "1:1/LOS Checklist" for P1, dated 03/27/23 and 03/28/23, was reviewed and found to be complete for all shifts. Upon interview, sitters who perform 1:1 and LOS observation stated that the "1:1/LOS Checklist" is completed each shift and then given to the nurse to keep with the medical record.

During interviews on 04/03/23 at 12:04 PM, Staff #3 and Staff #22 (Registered Nurses) stated that for patients on 1:1 or LOS observation, environmental rounds of patient rooms are conducted by nursing staff to monitor for ligature risks and items that patients can use to cause self-harm. Staff #3 and Staff #22 stated that environmental rounds are performed prior to a patient entering the room. Staff #3 and Staff #22 stated that nurses document and assess every 4 hours on a "checklist," conduct hourly rounding, and that Q15 minute documenting is done by the nurse's aide.

During a tour of 2N Annex, an interview was conducted with Staff #4 (Interim Nurse Manager of 2N Annex) on 04/03/23 at 12:15 PM. Staff #4 stated that nurses are expected to perform environmental rounds for patients on 1:1 and LOS observation every shift.

On 04/04/23 at 10:25 AM, an interview was conducted with Staff #6 (RN), who was the assigned RN for P1 during his/her attempt at self harm on 03/26/23. Staff #6 stated that he/she does not know how the patient was able to obtain a glass bottle, but believes a family member brought in the item. Staff #6 stated that every shift, environment rounds are done by the 1:1 sitter and that the RN does hourly rounding. Staff #6 stated he/she "must have missed it [glass bottle]" during his/her rounds. Staff #6 confirmed that after P1's attempts at self-harm, he/she did not receive any re-education from the facility regarding 1:1 or LOS observation or performing environmental rounds.

On 04/04/23 at 11:03 AM, a phone interview was conducted with Staff #25, the Nurse's Aide assigned to P1 on 03/26/23 from 7:00 AM to 3:00 PM. During this interview, Staff #25 stated he/she was on break when the incident occurred. Staff #25 stated Staff #24 was performing LOS observation for P1 while he/she was on break. Staff #25 stated that he/she performed an environmental round including the bathroom when his/her shift began and "nothing was around [P1]." Staff #25 stated, "I searched the room and didn't see any glass bottle." Staff #25 stated that P1 had a food tray with a cover on it on the side table and "maybe it was covered" because "I did not go through [his/her] food." Staff #25 stated that after this incidence occurred, he/she did not receive any re-education from the facility regarding 1:1 or LOS observation or performing environmental rounds.

On 04/04/23 at 12:33 PM, a phone interview was conducted with Staff #26 (Nurse's Aid), assigned to P1 on 03/27/23. Staff #26 stated that on 03/27/23, he/she came on shift at 3:00 PM to be the sitter for P1. Staff #26 stated he/she conducted environmental rounds when his/her shift began. Staff #26 stated, that during the incident, P1 pulled the item out of his/her underpants and attempted to cut his/her wrist. He/she stated they were told it was a broken glass screen protector from a cell phone, and that Staff #26 did not know how the patient was able to obtain the item. Staff #26 stated that after this incident, he/she did not receive any re-education from the facility regarding 1:1 or LOS observation or performing environmental rounds.

Upon interview on 04/06/23 at 10:30 AM, Staff #1 and Staff #2 stated that environmental rounds are expected to be completed for patients on 1:1 or LOS observation on Medical/Surgical units, however a policy was not developed.

The facility failed to provide care in a safe setting by ensuring Patient #1, who was on line of sight observation for high risk for suicide, was supervised in the bathroom. The patient was able to obtain a glass bottle from a visitor, enter the bathroom, lock the door, and cut his/her wrist with the glass bottle, while on line of sight observation. This resulted in an Immediate Jeopardy (IJ) being identified on 04/04/23 at 10:25 AM. On 04/04/23 at 2:00 PM, the IJ template was provided to facility administrative staff and an immediate removal plan was requested. On 04/06/23 at 3:10 PM, an acceptable IJ removal plan was received.

On 04/06/23, during an on-site visit, it was confirmed that the facility implemented the removal plan by re-educating all clinical staff that provide 1:1 and LOS observation for patients to facility policies and procedures. This was verified through review of educational materials, sign in sheets, staff interviews, and tours to observe patients on 1:1 and LOS observation. On 04/06/23 at 3:30 PM, the IJ was removed.