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This condition is not met as evidenced by:

Based on the seriousness of the noncompliance, the facility failed to substantially comply with this condition.

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to comply with this condition.

These following standards were cited and show a systemic nature of noncompliance with regards to patient rights as follows:

482.13 (c)(2) Tag A-0144 The information reviewed during the survey provided evidence that personnel failed to implement constant observation of an emergency department behavioral health, suicidal patient, resulting in patient elopement, for one medical record reviewed, by failing to complete the suicide risk assessment of emergency department behavioral health patients that expressed suicidal thoughts with intent to harm self, for two medical records reviewed, by failing to obtain a physician order for observation based on suicide risk assessment score for six medical records reviewed, by failing to implement physician order for observation of emergency department behavioral health patients for two medical records reviewed, and by failing to follow security procedures to eliminate safety risks of emergency department behavioral health patients that expressed suicidal thoughts with intent to harm self for four medical records reviewed.

Based on review of facility documents and medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to provide care in a safe setting by failing to complete the suicide risk assessment of emergency department behavioral health patients that expressed suicidal thoughts with intent to harm self in two of twenty medical records reviewed (MR12 and MR14), by failing to obtain a physician order for observation based on suicide risk assessment score in six of twenty medical records reviewed (MR2, MR5, MR7, MR12, MR13 and MR14), by failing to implement physician order for observation of emergency department behavioral health patients in two of twenty medical records (MR1 and MR18), and by failing to follow security procedures to eliminate safety risks of emergency department behavioral health patients that expressed suicidal thoughts with intent to harm self, in four of twenty medical records reviewed (MR1, MR5, MR13 and MR18).

Findings include:

"UPMC Policy and Procedure Manual ... Policy: HS-HD-PR-01* ... Subject: Patients'
Notice and Bill of Rights and Responsibilities" policy and procedure manual dated January 4, 2021, revealed, "I. Policy It is the policy of the UPMC to promote the interests and well-being of patients served in its United States based locations and to protect the interests of patients by the adoption of a Patients' Notice and Bill of Rights and Patient Responsibilities. ... Staff and Environment You have the right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self-image and comfort; ... V. Patients' Notice and Bill of Rights Behavioral Health Addendum You have the right to be treated with dignity and respect. ... ."


"UPMC Policy Safety Management Date: January 1, 2023, ... Policy Statement: The Emergency Department will maintain standards to ensure the safety of patients, visitors, and employees in the emergency care area. ... Patients who have demonstrated a danger to themselves or others should be attended at all times by a security guard, police officer, MH/MR worker, NPU staff person, or Emergency Department staff person. ... Safety pre-cautions for patients with mental health/suicide emergencies Therapeutic interventions Provide for patient's safety and security. Assess risk for suicide. Undress the patient and remove any items from the environment that may pose a danger. The patient should be visible and within close proximity to the nurses station. ... ."

Review of "UPMC Policy Nursing Subject: Care Attendant Utilization and Observation of Patients Date: May 24, 2023. I. Policy It is the policy of UPMC to provide for safe and therapeutic observation of patients according to individual patient needs. UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency departments, in accordance with established standards. ... IV Definitions: Safety Care Attendant: Provides patient care, support and constant observation in accordance with established policies and procedures under the direction of the RN/LPN physician, or provider with prescriptive authority. Routinely performs the UPMC patient care core responsibilities for Safety Care Attendants which includes, but is not limited to constant observation, activities of daily such as hygiene (bath and oral care), bed making, transfer and ambulation assistance, and patient comfort measures. Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the RN/LPN, physician, or provider with prescriptive authority. The Psychiatric Care Attendant will have limited direct responsibilities so that the patient remains in direct eyesight or, as ordered, within arm's reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going into patient's bathroom) or turn their back on the patient. Staff functioning in the Psychiatric Care Attendant role will be informed of the reason that the patient requires a Psychiatric Care Attendant by the assigned RN/LPN. Psychiatric Care Attendants may be used in non-behavioral health departments and hospitals. Constant Observation (CO): Whereby the staff continuously observes and may interact individually with he patient while keeping the patient in sight at all times. ... Patients on CO status may have issues that jeopardize their safety or the safety of others. They may exhibit behaviors or voice thoughts of suicidal, homicidal, or self-injurious intent that require staff or a Care Attendant to be observing them at all times to ensure their safety. ... V. Procedure Safety Care Attendant 1. The constant observation by Safety Care Attendant is a nurse driven intervention based on nursing judgement after alternative measures have proven ineffective. A physician's order is not required to initiate or discontinue a Safety Care Attendant. ...3. Constant Observation or Special Constant Observation in initiated by a registered nurse based on an appropriate assessment of the patient which is corroborated by the Unit Director (or designee) and/or nursing supervisor. ... Care Attendant 1. The request for a Psychiatric Care Attendant for suicidal or behavioral health patients requires the order of a physician. Nurses may initiate Constant Observation or Special Constant Observation of a patient for the safety of a patient until an order is secured. Discontinuation of a Psychiatric Care Attendant can only be completed with a physician's order. 2. Constant Observation or Special Constant Observation is to be maintained without disruption, and thus, the Psychiatric Care Attendant may have limited duties or care responsibilities, so the patient is in direct eyesight at all times. General Guidelines for Care Attendants 1. Care Attendants resources will be reasonably allocated and prioritized based on overall safety considerations in the following order: a. For patients with a positive suicidal/homicidal screening with or without a civil commitment (201 or above in PA) - a Psychiatric Care Attendant is required and ordered by the provider. i. In lieu of a Psychiatric Care Attendant, a tele-sitter (video monitoring) may be used for patients assessed at Moderate or Low risk for suicide. Patients assessed for High risk for suicide should be assigned a Psychiatric Care Attendant. B. For patients on a civil commitment (for example, 201 or above in PA) who are not suicidal/homicidal, the need for psychiatric care attendant may be determined by a licensed provider based on assessment of a patient's individual risk and protective factors, in collaboration with a psychiatric clinicians if available ... 5. Care Attendant responsibilities include, but are not limited to: a. Ensuring constant observation or special constant observation, providing protection to keep a patient from harming self or others, maintaining the patient's room in a neat and orderly fashion, and immediately report any changes in mental status and/or physical status to the RN/LPN caring for the patient. ... 2. Psychiatric Care Attendant - Their other assigned duties may be limited to ensure the patient is in eyesight (CO) or within arm's distance (SCO) at all times per the physician order. ... ."

"UPMC Policy Nursing Screening and Care of the Suicidal Patient: Purpose: The purpose of this policy to provide the steps that Somerset Hospital will use to screen patients at risk for suicide and ensure their safety while in the care of our services, as well as, to ensure identified patients have the appropriate resources to maintain safety after discharge ... Healthcare organizations should have measures in place to assess for and detect suicidal ideations, as well as, have plans in place to care for individuals who have been deemed at risk. ... Procedure: All patients seeking care will be screened for suicide ideation. If through screening, a patient is found to be at risk for suicide a more comprehensive risk assessment will be completed. The results of the risk assessment will determine level of supervision required, and interventions needed to ensure safety of the patient. ... previous suicide attempts, ... feelings of hopelessness ... Initial Assessment During initial assessments of patients the registered nurse will complete Columbia Suicide Patient Safety Screener consisting of 3 to 6 questions. Patient Safety Screener (suicide screen) ... The screener is completed by the unit who first contacts the patient. ... levels of Supervision: Patient assessed as at risk-yes to questions 1 & 2 includes patients that have expressed suicide ideation, the patient is placed on constant observation by staff, suicide precautions are implemented, add event report into safety portal and notify supervisor, for patients identified as a risk a notification of the physician and behavioral health is completed. Patient assessed as high risk-yes to questions 3 through 6: Include patients that have had a suicide attempt, or have expressed clear intent. The patient is placed on constant observation by staff. Suicide precautions are implemented. ... For patients identified as a risk a notification of the physician and behavioral health is completed. The attending physician shall be made aware of the risk assessment findings and level of supervision required. An order is generated based on screening criteria. ... Patients who screen as at risk still require constant observation to mitigate environmental risk factors. ... Patients with identified Suicide Risk: For any patient that is identified as a suicidal risk and admitted in the emergency department or general medical floors the following shall be instituted for suicide precautions. Removal of harmful objects from the room. No pens, or sharp objects. Removal of garbage cans, contact housekeeping for alternative trash collection containers. Removal of non-essential furniture and equipment. ... Inventory of patient belongings for potential harmful items. Patient clothing must be removed and patient placed into a gown. Special gowns with no strings should be used. Patients shall be accompanied to the restroom and may not be left unattended. ... The patient must be visible to the responsible observer at all times. ... For patients in constant observation, sitters will never leave patients unattended. Even when visitors or family is present, sitter must remain in the room. ... ."

1. Review of MR1 revealed that the patient presented to UPMC Somerset Emergency Department on July 5, 2023, at 5:55 PM following a clinic appointment where the patient was found in the bathroom by a counselor after cutting both both wrists with a three inch folding knife. MR1 Suicide Safety Screen conducted at 6:04 PM confirmed "High Suicide Precaution Orders High Risk-Constant Observation." MR1 revealed a physican order for a "1:1 Sitter Suicide-Constant Observation" on July 5, 2023, at 7:13 PM. MR1 nursing documentation revealed that at 7:20 PM the patient came out of room and headed toward the ambulance bay doors and was told to return to room. Further documentation of MR1 revealed that the patient eloped at approximately 8:00 PM.

2. Tour of the Emergency Department on July 31, 2023, was conducted with EMP5 and revealed four Emergency Department patient bays (rooms 2, 3-Cardiac Room, 8 and 9), two on either side of the nurse's station, any of which could be occupied by a patient that requires constant visual observation. Further observation of patient bays revealed that a patient in room 2, 3-Cardiac Room, 8, and/or 9 would not be visualized from the nurses station. Review of MR1 revealed that the patient was admitted to room 3-Cardiac Room.

3. Interview with EMP4 on July 31, 2023, at approximately 11:00 AM confirmed that the patient was not changed into a hospital gown, that the patient had attempted to leave prior to actual elopement, and that according to hospital policy the patient should have been placed in a hospital gown, and belongings should have been collected by staff and secured at the nurse's station.

4. Telephone interview with EMP6 on August 3, 2023, confirmed that 1:1's are not typically ordered because the facility does not have the staff to sit with a patient. EMP6 also confirmed that the patient related to this investigation, MR1, was never changed into a hospital gown, personal belongings were never removed from the patient and the cardiac room was not ligature risk free.

5. Review of MR12 and MR14 failed to reveal documented evidence of a suicide risk assessment.

Review of facility electronic documentation dated August 3, 2023, from EMP1 confirmed the above finding.

6. Review of MR2, MR5, MR7, MR12, MR 13 and MR14 failed to review documented evidence of a physician order for observation based on suicide risk assessment score-High Suicide Risk.

Review of facility electronic documentation dated August 3, 2023, from EMP1 confirmed the above finding.

7. Review of MR1 and MR18 failed to reveal documented evidence of implementation of physician's order for Constant Observation.

Review of facility electronic documentation dated August 3, 2023, from EMP1 confirmed the above finding.

8. Review of MR1, MR5, MR13 and MR18 failed to reveal documented evidence that security procedures were conducted to eliminate safety risks.

Review of facility electronic documentation dated August 3, 2023, from EMP1 confirmed the above finding.