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Based on observations, interviews, medical record, and facility document and policy review, the facility failed to effectively protect and promote each patient's rights for patients on the Child/Adolescent (C/A) Unit as evidenced by:

A. Based on observation, interview, and record review, the facility failed to ensure patients on the (C/A) unit received care in a safe environment when:

1. Patients on the C/A unit were not consistently monitored every 15 minutes according to facility policy and Physician (MD) order on 6 of 6 selected dates;

2. An environment of care "Shift-to-Shift Checklist" was not completed on the 12/5/23 night shift; and

3. Facility-wide, physical environment ligature [a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] -risk assessments were not completed in accordance with facility policy or professional standards of practice.

These failures resulted in the suicide of a patient (Patient 1) and contributed to an unsafe environment for patients on the C/A unit by leaving them unsupervised for extended periods of time in an environment that was inadequately assessed for immediate safety concerns. (Refer to A 0144); and

B. Based on observation, interview, and record review, the facility failed to protect patients on the Child/Adolescent (C/A) Unit from neglect when staff failed to provide necessary (and facility required) supervision of patients on 6 of 6 selected dates to ensure they remained free from physical harm.

This failure resulted in the suicide of a patient (Patient 1) and had the potential to cause additional emotional distress, harm, and even death to all unsupervised patients on the C/A unit. (Refer to A 0145).

The cumulative effect of these failures resulted in the hospital's inability to effectively protect and promote each patient on the Child/Adolescent (C/A) Unit's right to receive care in a safe environment and remain free from all forms of abuse in accordance with the statutorily-mandated Conditions of Participation Patient Rights.

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Based on observation, interview, and record review, the facility failed to ensure patients on the Child/Adolescent (C/A) unit received care in a safe environment when:

1. Patients on the C/A unit were not consistently monitored every 15 minutes according to facility policy and Physician (MD) order on 6 of 6 selected dates (11/14/23, 11/17/23, 11/30/23, 12/3/23,12/4/23, and 12/6/23);

2. An environment of care "Shift-to-Shift Checklist" was not completed on the 12/5/23 night shift; and

3. Facility-wide, physical environment ligature-[a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] risk assessments were not completed in accordance with facility policy or professional standards of practice.

These failures resulted in the suicide of a patient (Patient 1) and contributed to an unsafe environment for patients on the C/A unit by leaving them unsupervised for extended periods of time in an environment that was inadequately assessed for immediate safety concerns.

The State Survey Agency (SA) determined the facility's noncompliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to patients.

On 12/20/23 at 4:03 p.m., the SA provided the CMS Immediate Jeopardy (IJ) Template to the Quality Director and Chief Executive Officer and informed them that IJ existed and began on 12/20/23. The IJ was related to 42 CFR 482.13(c)(2) - Patient Rights to receive care in a safe setting (A0144). On 12/20/23 at 7:43 p.m., the facility provided an acceptable IJ removal plan.

On 12/21/23 at 11:53 a.m., the survey team validated the facility's corrective actions and removed the IJ onsite. The facility remained out of compliance at A0144.

Findings:

1. Patients on the C/A unit were not consistently monitored every 15 minutes according to facility policy and MD order on 6 of 6 selected dates.

During a review of Patient 1's "H&P [History & Physical]," dated 12/4/23, the H&P indicated Patient 1 was admitted to the facility for "self harm thoughts." The H&P further indicated Patient 1 had taken the family car and while driving, had hit a barrier at an unknown speed. The H&P further indicated the patient had left a "goodbye letter in car."

During a review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 had a history of bipolar disorder (a mental health condition that causes extreme mood swings), and major depressive disorder (a mental condition characterized by a persistently depressed mood often with symptoms such as suicidal thoughts) with several suicide attempts. The admission note further indicated Patient 1's risk factors included multiple past suicide attempts by various methods including hanging, overdose, and jumping from a bridge.

During a continued review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 was a danger to self due to a mental health disorder. The admission note indicated Patient 1 was to be admitted, "under observation level: Every 15 minutes."

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. with the Chief Executive Officer (CEO) and the Nurse Educator (NE) of room 33 (Patient 1's former room), the CEO stated, "Patient rooms are ligature resistant, not ligature free, and that is why we do rounds [observations of patients]." NE stated during patient rounding, staff need to go into the patient room to check on the patient and if a patient was identified as a higher risk, their levels of observation would be increased.

During a concurrent observation and interview on 12/18/23 at 11:10 a.m. with Manager for Protective Services (MPS) and NE, video footage during the night of 12/5/23-12/6/23 of the C/A unit hallway outside of room 33 (Patient 1's room) was viewed. MPS stated the camera only recorded video footage when motion activated, meaning there must be movement (such as a person walking) in the camera frame for the video to record.

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage during the night of 12/5/23-12/6/23 of the C/A unit hallway outside of Patient 1's room was viewed and the following was observed:

a) The video footage indicated two individuals walking in the hallway, entering patient rooms and then walking back down the hallway out of camera frame. The NE stated the two individuals were staff members conducting what appeared to be shift-to-shift handoff rounds at the 12/5/23 11:20 p.m. time stamp.

b) The NE stated the video further indicated a staff member looking in Patient 1's room and other patient rooms (conducting patient rounds) in the C/A unit hallway at the 12/5/23 11:42 p.m., and 12/6/23 12:01 a.m., and 12:14 a.m. timestamps.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 12:22 a.m., the note indicated Patient 1 was observed "lying in bed resting facing away from door, continue to monitor every 15 minutes ATC [Around The Clock] by floor staff for safety." The note further indicated Patient 1's level of observation was every 15 minutes, and "Self Harm Precautions" were listed as "every 15 minute checks."

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage during the night of 12/5/23-12/6/23 of the C/A unit hallway outside of Patient 1's room was viewed and the following was observed:

a) The NE stated the video indicated a staff member looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:23 a.m. timestamp.

b) The NE confirmed the video indicated a staff member again looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:47 a.m. time stamp.

c) MPS stated the next time on video footage a staff member was observed conducting rounds in patient rooms was at the 12/6/23 1:00 a.m., 1:18 a.m., and 1:32 a.m. timestamps. NE stated it appeared Patient 1's room was "skipped" at those times.

d) MPS stated the video footage of the C/A unit hallway outside of Patient 1's room indicated a time leap from 12/6/23 at 1:37 a.m. to 2:20 a.m., to mean no activity from staff or any other person was recorded or had taken place in the hallway, such as patient rounds in any patient room, for that 43-minute time period.

During concurrent observation and interview on 12/18/23 at 11:40 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed and the following was observed:

a) MPS stated the next observed time a staff member conducted rounds in Patient 1's room was not until 12/6/23 at 2:41 a.m. MPS stated according to the video footage, it was approximately 114 minutes before a staff member conducted an additional safety check on Patient 1.

b) NE stated a staff member was observed entering Patient 1's room at the 12/6/23 2:41 a.m. timestamp. The video footage indicated about a minute later, at the 2:42 a.m. timestamp, an additional staff member was observed running into Patient 1's room.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 4:46 a.m., the note indicated Patient 1 was found in her room hanging and unconscious at around 2:45 a.m. that morning. The note further indicated CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating) was started for about 10-15 minutes before EMS (Emergency medical services, also known as ambulance services or paramedic services) arrived, "then after a while EMS announced pt [patient] passed. Police arrived with coroners [an official who investigates violent, sudden, or suspicious deaths] office [name of coroner] and pt was taken."

During an interview on 12/19/23 at 10:25 a.m. with Registered Nurse (RN) 3, RN 3 stated all patients on the C/A unit are on every 15 minute checks, or observations, unless a more frequent observation level is noted in a physician order. RN 3 stated the expectation with patient rounds was to lay eyes on each patient to ensure they were safe.

During an interview on 12/19/23 at 11:40 a.m. with Risk Officer (RO) and the Quality Director (QD), the RO stated during the time staff did not round on Patient 1, the patient had time to accomplish her suicide. The RO stated rounds were documented in Patient 1's clinical record but not completed based on the video of the C/A unit hallway. The QD stated ligature risk is mitigated by increasing observation of the patients.

During a concurrent observation and interview on 12/20/23 at 10:22 a.m. with RO, additional camera footage of five additional dates of the C/A unit patient room hallway, were reviewed. RO stated for dates:

a) 11/14/23 between 3:21 a.m. and 4:08 a.m. (approximately 47 minutes);

b) 11/17/23 between 4:21 a.m. and 5:12 a.m. (approximately 51 minutes);

c) 11/30/23 between 4:42 a.m. and 5:59 a.m. (approximately one hour and seven minutes);

d) 12/3/23 between 3:26 a.m. and 4:14 a.m. (approximately 48 minutes), and then again between 4:55 a.m. and 5:52 a.m. (an additional approximate 57 minutes); and

e) 12/4/23 between 4:34 a.m. and 5:32 a.m. (approximately 58 minutes); the camera footage indicated no staff or patient activity was observed in the hallway (such as patient rounds). RO stated the camera footage indicated patient rounding was being conducted "more like hourly" and not every 15 minutes per facility requirement.

During an interview on 12/21/23 at 12:45 p.m. with the Director of Nursing (DON) and the Unit Manager (UM) 1, UM 1 stated the expectation for patient rounds was staff were to physically lay eyes on the patients to document location and activity. UM 1 stated if patients were asleep, staff were to ensure the patient was breathing by observing the rise and fall of the chest. UM 1 further stated prior to the death of Patient 1, she was not aware patient rounding was not being done, and the expectation was documentation of rounding should be in real time. UM 1 stated, "everybody knows rounds should be done" and "anyone and everyone can do rounds." UM 1 further stated patient rounds are done to ensure the safety of patients and to ensure they do not harm themselves.

During a review of the facility's policy and procedure (P&P) titled, "Precaution and Observation Levels based on Patient Assessment," dated 1/15/2021, the P&P indicated the purpose, "To ensure the safety of all patients admitted to the inpatient unit, a systematic and clearly defined observation plan is implemented." The policy further indicated, "It is the policy of [Facility Name] to ensure that the clinical status of all patients and the general safety of the units is ascertained on a regular basis by nursing staff and to provide a safe and secure environment for patients during their hospitalization."

During a review of the same facility P&P titled, "Precaution and Observation Levels based on Patient Assessment," dated 1/15/2021, the P&P further indicated, "All patients are observed at a minimum every 15 minutes for the entire admission." The policy further indicated, "Rounding on patient includes: patient location, patient activity/behavior, observation of patient breathing/respirations by observing rise and fall of the chest as an example, that patient has no signs of distress and the environment the patient is in is safe."

During a review of the facility's policy and procedure (P&P) titled, "Unit Patient Rounds," dated 3/12/2021, the P&P indicated, "It is the policy at [name of facility] that visual and verbal (where applicable) contact is made on all patients at least every fifteen minutes to assure the safety of patients and staff." The policy further indicated, "Direct visual observation with corresponding documentation is a fundamental feature of the safe and therapeutic milieu at [Facility Name]." The policy further indicated, "The patient whereabouts are documented every fifteen minutes as directly visualized by the staff member assigned to conduct rounds."

2. An environment of care "Shift-to-Shift Checklist" was not completed on the 12/5/23 night shift.

During a concurrent observation and interview on 12/18/23 at 9:45 a.m. with NE and CEO in room 33 (Patient 1's former room) on the C/A unit, a metal track was observed affixed to the top of a door frame to the bathroom. The metal track contained white clips that were able to slide back and forth along the track. The NE stated the clips were meant to hold a privacy curtain to the bathroom, should a patient request one. Further observations of the bathroom revealed a shower stall with a shower curtain, curtain clips and a track. The shower curtain was observed suspended from only one shower clip. The remaining clips were observed attached to the shower curtain and the track.

During additional observations of the C/A unit on 12/18/23 at 9:45 a.m., additional items observed in room 33 included: patient clothing stored in bedside shelves, a paper bag on the floor with various items of patient clothing (including a bra), and petroleum jelly in a medicine cup on the bedside table.

In a concurrent interview on 12/18/23 at 9:45 a.m., the CEO and NE were asked if the patient rooms were routinely assessed for safety, e.g., ligature risks and they said "shift-to-shift rounds" were completed.

Observations of patient room 32 on the C/A unit were conducted with NE on 12/18/23 at 10 a.m. No privacy curtain, curtain clips or track were observed in the bathroom door frame of room 32. A shower curtain (made of a thick, heavy fabric) was observed just outside the shower stall in the bathroom, hanging from fabric tags with Velcro. The Velcro tabs were secured to a curtain track. Additional items observed in room 32 included a jacket with a metal zipper and a set of headphones.

During observations of patient room 35 on the C/A unit on 12/18/23 at 10:05 a.m., a privacy curtain was observed hanging from white curtain clips and secured to a curtain track in the bathroom door frame. Inside the bathroom, a shower stall was observed with a shower curtain suspended from white clips and track.

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. of the metal track affixed to the top of the door frame to the bathroom in room 33 on the C/A unit with the NE and CEO, the Department was able to thread a bedsheet through the track, over the plastic clips, and bear weight on the sheet as if to hang from it. Both the CEO and the NE acknowledged the immediate ligature safety concern and the metal tracks/clips would be removed from all patient rooms "today."

On 12/18/23, the Department requested the facility provide documented evidence that shift-to-shift environmental rounds were completed on the C/A Unit between September and December 2023.

On 12/19/23, the facility provided the Department with three "Shift-to-Shift Checklists" completed by staff of the C/A Unit. They were dated: 8/31/23, 9/3/23 and 12/18/23. The facility did not provide a C/A Unit "Shift-to-Shift Checklist" from 12/5/23. No other "Shift-to-shift" Checklists" were provided.

From a review of the three completed C/A Unit "Shift-to-Shift Checklists" (checklist last revised 1/3/19), staff used the checklists to direct their unit environmental rounds. The staff documented using "check marks" to indicate that specific areas on the unit were observed and met environmental safety "compliance expectations". More specifically, the 8/31/23, 9/3/23 and 12/18/23 checklists reflected only three days patient rooms were assessed to be: "Floors clear of clothes and linen. No food stored in room. No extra linen in cubby. Appropriate chair in room. 1 trash can in room. Shower curtain present. Base board intact. [and] All in good working order."

During a group interview with facility leadership on 12/19/23 at 11:50 a.m., the question was asked if, prior to 12/5/23, the privacy curtains, shower curtains, clips or tracks were identified as unsafe, a ligature-risk, or unsuitable for patients at risk of suicide. The CEO explained the facility has a policy that high risk patients must be observed, mitigating the potential use of those items for self-harm. The Quality Director (QD) acknowledged shift-to-shift environment of care unit rounds on the C/A Unit had not been completed consistently.

During an interview with the DON and C/A UM 1 on 12/21/23 at 1 p.m., UM 1 explained shift-to-shift rounds were equivalent to an environmental shift-to-shift "hand-off". UM 1 explained the importance of the environmental rounds for patient safety; the checklists assist with staff awareness of items in the patient's room that may increase a patient's risk for self-harm. Room assessments can be completed as needed, to eliminate environmental risk to patients, UM 1 added. UM 1 acknowledged an environmental "Shift-to-Shift Checklist" from 12/5/23 was missing.

During a record review of a 3/12/21 facility policy titled, "Shift to Shift Rounds," it directed, "Immediately following change of shift report, one member of the incoming shift and one member of the off-going shift is assigned to conduct unit rounds."

During a record review of facility policy titled, "Identification of Patients at Risk for Suicide," dated 6/6/2019, indicated that the immediate safety needs and most appropriate treatment setting for each patient should be evaluated upon admission and throughout the patient's hospital stay. Environmental factors and features may increase a patient's risk for suicide, such as access to contraband and other lethal means of suicide. Environmental precautions are taken for all inpatients at [the facility].

On November 27, 2018, the Joint Commission published its National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide ("R3 Report Requirement and Reference", Issue 18 Updated 11/20/19). NPSG 15.01.01, Element of Performance 1 requires "the organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). For psychiatric hospitals: the hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). The health care environment, including patient rooms, patient bathrooms, corridors, and common patient care areas can contain features that patients can use to attempt suicide. The most common hazards for suicide risk are ligature anchor points that can be used for hanging. However, there are many other types of hazards, so it is important to do a thorough assessment of the environment to minimize all potential suicide risks."

3. Facility-wide physical environment, ligature-risk assessments, were not completed in accordance with facility policy or professional standards of practice.

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. of the metal track affixed to the top of the door frame to the bathroom in room 33 on the C/A unit with the NE and CEO, the Department was able to thread a bedsheet through the track, over the plastic clips, and bear weight on the sheet as if to hang from it. Both the CEO and the NE acknowledged the immediate ligature safety concern and the metal tracks/clips would be removed from all patient rooms "today." The CEO stated, "Patient rooms are ligature resistant, not ligature free, and that is why we do rounds."

During an interview on 12/20/23 at 11:30 a.m. with Environment of Care Health and Safety Specialist (EOC) 1 and EOC 2, both acknowledged it was part of their responsibility during their employment at the facility to facilitate and conduct environment of care and ligature risk assessments. EOC 2 stated multiple departments participate in the physical environment risk assessments. EOC 2 stated she had not completed or participated in a ligature risk assessment since her employment started in May 2023 and could not speak to what was completed prior to May 2023. EOC 2 stated, "Environmental rounding of the facility occurs twice a year;" and "the plan" was to complete an environmental ligature risk assessment the "Fall of 2023." During the interview, the Department requested any and all documentation related to environmental ligature risk assessments completed in the last 2 years.

During a concurrent observation and interview of the C/A Unit, on 12/20/23 at 12:30 p.m. with EOC 1 and EOC 2, observations were made of the shower curtains, clips and curtain tracks remaining in the bathrooms of patient rooms 32, 33 and 35. EOC 1 and EOC 2 would not confirm if the shower curtains, clips or tracks were identified as ligature risks in past environmental or ligature-risk assessments. EOC 2 acknowledged all three shower curtains and accessories posed an immediate and equal ligature risk to patients.

During a review of the facility's "Physical Environment Assessment" (ligature risk assessment), the document included a floor map, a Physical Environment Risk Assessment Tool, and photographs. A review of the "Physical Environment Assessment" and attachments revealed it was last performed by the facility on 9/18/20.

During an interview on 12/20/23 at 3 p.m. with the QD, the QD acknowledged that other than the ligature risk assessment completed after Patient 1's death on 12/6/23, the last ligature risk assessment of the facility was completed September of 2020.

During a review of the Joint Commission's "National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide ("R3 Report Requirement and Reference", Issue 18 Updated 11/20/19)," published 11/27/18, the publication indicated, Element of Performance 1 requires "the organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). For psychiatric hospitals: the hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). The health care environment, including patient rooms, patient bathrooms, corridors, and common patient care areas can contain features that patients can use to attempt suicide. The most common hazards for suicide risk are ligature anchor points that can be used for hanging. However, there are many other types of hazards, so it is important to do a thorough assessment of the environment to minimize all potential suicide risks."

During a record review of the 7/5/19 facility policy titled, "Suicide Prevention: Safety of the Environment", the facility used "Ligature Risk Assessment Methodology" and a "Physical Environmental Risk Assessment Tool" in its approach to their suicide risk assessment and management. "Environmental risk assessments are conducted by identified team members (i.e., safety officer, engineer, clinical representative). The assigned risk assessment team will visit the patient care area and check all ligature points identified in the tool. The team will rate (low, medium, high) each of the items listed on the tool based on the level of risk prior to mitigation. Environmental risk assessments are completed and reviewed annually or when there is any significant change in the environment or operations (i.e., change of use, modification of the building, after a serious adverse incident involving suicide or attempted suicide using a ligature, or change in patient population served warranting reassessment). Completed risk assessments are maintained and kept at the local affiliate level."

During a review of the facility's policy and procedure (P&P) titled, "Suicide Prevention: Safety of the Environment," dated 7/5/2019, the P&P indicated, "[Name of organization] is committed to providing a safe environment where patients who are at risk for suicide are receiving treatment. Where it is not possible to remove structures identified as ligature points and safety risks have been identified, the organizations will adopt other risk controls and mitigation measures based on the patient population served."

Based on observation, interview, and record review, the facility failed to protect patients on the Child/Adolescent (C/A) Unit from neglect when staff failed to provide necessary, and facility required, supervision of patients on 6 of 6 selected dates (11/14/23, 11/17/23, 11/30/23, 12/3/23,12/4/23, and 12/6/23) to ensure they remained free from physical harm.

This failure resulted in the suicide of a patient (Patient 1) and had the potential to cause additional emotional distress, harm, and even death to all unsupervised patients on the C/A unit.

Findings:

During a review of Patient 1's "H&P [History & Physical]," dated 12/4/23, the H&P indicated Patient 1 was admitted to the facility for "self harm thoughts." The H&P further indicated Patient 1 had taken the family car and while driving "had hit a barrier at an unknown speed." The H&P further indicated the patient had left a "goodbye letter in car."

During a review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 had a history of bipolar disorder (a mental health condition that causes extreme mood swings), and major depressive disorder (a mental condition characterized by a persistently depressed mood often with symptoms such as suicidal thoughts) with several suicide attempts. The admission note further indicated Patient 1's risk factors included multiple past suicide attempts by various methods including hanging, overdose, and jumping from a bridge.

During a continued review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 was a danger to self due to a mental health disorder. The admission note indicated Patient 1 was to be admitted, "under observation level: Every 15 minutes."

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. with the Chief Executive Officer (CEO) and the Nurse Educator (NE) of room 33 (Patient 1's former room), the CEO stated, "Patient rooms are ligature [a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] resistant, not ligature free, and that is why we do rounds [observations of patients]." The NE stated during patient rounding, staff need to go into the patient room to check on the patient, and if a patient was identified as a higher risk, their levels of observation would be increased.

During a concurrent observation and interview on 12/18/23 at 11:10 a.m. with Manager for Protective Services (MPS) and NE, video footage during the night of 12/5/23-12/6/23 of the C/A unit hallway outside of Patient 1's room was viewed. The video footage indicated two individuals walking in the hallway, entering patient rooms and then walking back down the hallway out of camera frame. The NE stated the two individuals were staff members conducting what appeared to be shift-to-shift handoff rounds at the 12/5/23 11:20 p.m. time stamp. The NE stated the video further indicated a staff member looking in Patient 1's room and other patient rooms (conducting patient rounds) in the C/A unit hallway at the 12/5/23 11:42 a.m., and 12/6/23 12:01 a.m., and 12:14 a.m. timestamps. The NE stated the expectation was for staff to document patient rounds in real time, to mean the time the staff physically checked on the patient would reflect the time the rounds were documented in each patient's clinical record.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 12:22 a.m., the note indicated Patient 1 was observed "lying in bed resting facing away from door, continue to monitor every 15 minutes ATC [Around The Clock] by floor staff for safety." The note further indicated Patient 1's level of observation was every 15 minutes, and "Self Harm Precautions" were listed as "every 15 minute checks."

During a continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage during the night of 12/5/23-12/6/23 of the C/A unit hallway outside of Patient 1's room was viewed. The NE stated the video indicated a staff member looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:23 a.m. timestamp.

During a review of Patient 1's "Safety Checks" Flowsheet, dated 12/6/23, the flowsheet indicated documented evidence of a safety check on the patient conducted at 12:28 a.m. The safety check documentation indicated Patient 1's location was "Patient Room," and Patient 1's activity was "Sleeping, breathing noted."

During a continued review of Patient 1's "Safety Checks" Flowsheet, dated 12/6/23, the flowsheet indicated documented evidence of additional safety checks conducted on Patient 1 at 12:44 a.m., with the same location of Patient 1, "Patient Room," and same Patient 1 activity, "Sleeping, breathing noted."

During a continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. The NE confirmed the video indicated a staff member looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:47 a.m. time stamp.

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room was viewed. MPS stated the next time on video footage a staff member was observed conducting rounds in patient rooms was at the 12/6/23 1:00 a.m., 1:18 a.m., and 1:32 a.m. timestamps. NE stated it appeared Patient 1's room was "skipped" at those times.

During a review of Patient 1's "Safety Checks" Flowsheet, dated 12/6/23, the flowsheet indicated documentation of safety checks on Patient 1 conducted at 1:01 a.m., 1:14 a.m., and 1:29 a.m., all with the same Patient 1 location "Patient Room," and same Patient 1 activity "Sleeping, breathing noted."

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage the night of 12/5/23-12/6/23 of the C/A unit hallway outside of Patient 1's room was viewed. MPS stated the video footage of the C/A unit hallway outside of Patient 1's room indicated a time leap from 12/6/23 at 1:37 a.m. to 2:20 a.m., to mean no activity from staff or any other person was recorded or had taken place in the hallway, such as patient rounds in any patient room, for that 43-minute time-period.

During a review of Patient 1's "Safety Checks" Flowsheet, dated 12/6/23, the flowsheet indicated documentation of safety checks on Patient 1 conducted at 1:45 a.m., 2:00 a.m., 2:15 a.m., and 2:28 a.m., all with the same Patient 1 location "Patient Room," and same Patient 1 activity "Sleeping, breathing noted."

During concurrent observation and interview on 12/18/23 at 11:40 a.m. with MPS and NE, video footage of the C/A unit hallway the night of 12/5/23-12/6/23 outside of Patient 1's room was viewed. MPS stated the next observed time a staff member conducted rounds in Patient 1's room was not until 12/6/23 at 2:41 a.m. MPS stated according to the video footage, it was approximately 114 minutes before a staff member conducted an additional safety check on Patient 1.

During concurrent observation and interview on 12/18/23 at 11:40 a.m. with MPS and NE video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. NE stated a staff member was observed entering Patient 1's room at the 12/6/23 2:41 a.m. timestamp. The video footage indicated about a minute later, at the 2:42 a.m. timestamp, an additional staff member was observed running into Patient 1's room.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 4:46 a.m., the note indicated Patient 1 was found in her room hanging and unconscious at around 2:45 a.m. that morning. The note further indicated CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating) was started for about 10-15 minutes before EMS (Emergency medical services, also known as ambulance services or paramedic services) arrived, "then after a while EMS announced pt [patient] passed. Police arrived with coroners [an official who investigates violent, sudden, or suspicious deaths] office [name if coroner] and pt was taken."

During a concurrent observation, interview, and record review on 12/18/23 at 2:48 p.m. with Risk Officer (RO) and NE, video footage of the C/A unit nurse's station was viewed with Patient 1's "Safety Checks" Flowsheet, dated 12/6/23. NE stated the safety check flowsheet indicated RN 1 had documented the safety check rounds conducted on Patient 1 at times RN 1 was visible on the C/A unit nurse's station video (and not conducting rounds in the hallway). NE further stated the camera footage of the nurse's station indicated RN 1, at one point, visibly documenting rounds of patient rooms while sitting at the nurse's station. NE confirmed the staff responsible (RN ' s 1 and 2) for documenting safety checks in Patient 1's record were the same two staff members observed at the nurse' s station during that timeframe.

During an interview on 12/19/23 at 11:40 a.m. with RO and the Quality Director (QD), the RO stated during the time staff did not round on Patient 1, the patient had time to accomplish her suicide. RO stated rounds were documented in the clinical record but not completed based on review of the video of the C/A unit hallway. The QD stated ligature risk is mitigated by increasing observation of the patients.

During a concurrent observation and interview on 12/20/23 at 10:22 a.m. with RO, additional camera footage of five additional dates of the C/A unit patient room hallway, were reviewed. RO stated for dates 11/14/23 between 3:21 a.m. and 4:08 a.m. (approximately 47 minutes); 11/17/23 between 4:21 a.m. and 5:12 a.m. (approximately 51 minutes); 11/30/23 between 4:42 a.m. and 5:59 a.m. (approximately one hour and seven minutes); 12/3/23 between 3:26 a.m. and 4:14 a.m. (approximately 48 minutes), and then again between 4:55 a.m. and 5:52 a.m. (an additional approximate 57 minutes); and 12/4/23 between 4:34 a.m. and 5:32 a.m. (approximately 58 minutes), the camera footage indicated no staff or patient activity was observed in the hallway (such as patient rounds). RO stated the camera footage indicated patient rounding was being conducted "more like hourly" and not every 15 minutes per facility requirement.

During an interview with the QD on 12/21/23 at 10:14 a.m., the QD acknowledged there was evidence of documented patient safety checks in C/A unit patient records and no corresponding evidence of patient rounds being conducted on the C/A unit at those specified times for dates 11/14/23, 11/17/23, 11/30/23, 12/3/23, and 12/4/23.

During an interview on 12/21/23 at 12:45 p.m. with the Director of Nursing (DON) and the Unit Manager (UM) 1, UM 1 stated the expectation for patient rounds was staff were to physically lay eyes on the patients to document location and activity. UM 1 stated if patients were asleep, staff were to ensure the patient was breathing by observing the rise and fall of the chest. UM 1 further stated prior to the death of Patient 1, she was not aware patient rounding was not being done, and the expectation was documentation of rounding should be in real time. UM 1 stated, "everybody knows rounds should be done" and "anyone and everyone can do rounds." UM 1 further stated patient rounds are done to ensure the safety of patients and to ensure they do not harm themselves.

During a review of a facility document titled, "Rights of Minors," dated 2/23/15, the document indicated, "NOTICE TO MINORS ...2. You are to be provided with a patient rights ' booklet published by the State Department of Mental Health describing the rights of minors in mental health facilities."

During a review of the facility 's booklet titled "Rights for Individuals in Mental Health Facilities," undated, the booklet indicated, "You have the right to be free from abuse, neglect, or harm ...You also have the right to be free from potentially harmful situations or conditions."

During a review of the facility ' s policy and procedure (P&P) titled, "Suicide Prevention: Safety of the Environment," dated 7/5/2019, the P&P indicated, "[Name of organization] is committed to providing a safe environment where patients who are at risk for suicide are receiving treatment. Where it is not possible to remove structures identified as ligature points and safety risks have been identified, the organizations will adopt other risk controls and mitigation measures based on the patient population served."

During a review of the facility ' s policy and procedure (P&P) titled, "Precaution and Observation Levels based on Patient Assessment," dated 1/15/2021, the P&P indicated, "Purpose To ensure the safety of all patients admitted to the inpatient unit, a systematic and clearly defined observation plan is implemented. This observation plan also respects the dignity and privacy of the patient to the extent possible according to privacy requirements and to maximize patient ' s level of functioning." The policy further indicated, "It is the policy of [Name of Facility] to ensure that the clinical status of all patients and the general safety of the units is ascertained on a regular basis by nursing staff and to provide a safe and secure environment for patient during their hospitalization."

During a review of the same facility P&P titled, "Precaution and Observation Levels based on Patient Assessment," dated 1/15/2021, the P&P further indicated, "All patients are observed at a minimum every 15 minutes for the entire admission." The policy further indicated, "Rounding on patient includes: patient location, patient activity/behavior, observation of patient breathing/respirations by observing rise and fall of the chest as an example, that patient has no signs of distress and the environment the patient is in is safe."

During a review of the facility ' s policy and procedure (P&P) titled, "Unit Patient Rounds," dated 3/12/2021, the P&P indicated, "It is the policy at [name of facility] that visual and verbal (where applicable) contact is made on all patients at least every fifteen minutes to assure the safety of patients and staff." The policy further indicated, "Direct visual observation with corresponding documentation is a fundamental feature of the safe and therapeutic milieu at [name of facility]." The policy further indicated, "The patient whereabouts are documented every fifteen minutes as directly visualized by the staff member assigned to conduct rounds."

During a review of the facility ' s policy and procedure (P&P) titled, "Foundation Policy on Abuse and Neglect," dated 3/12/2021, the P&P indicated, "Child Abuse: A child is defined as an individual under the age of 18 years old. Child maltreatment is any act or failure to act of the parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which puts the child at imminent risk of serious harm." The policy further indicated, "Neglect: acts of omission and failure to meet a child ' s basic needs, including food, clothing, medical care, and a safe environment."

Based on observation, interview and document review, the hospital failed to maintain an effective data-driven Quality Assessment and Performance Improvement (QAPI) Program as evidenced by:

1. The facility failed to analyze the extent and severity of the contributing factors (Patients on the Child/Adolescent unit were not consistently monitored every 15 minutes and facility-wide, physical environment ligature [a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] -risk assessments were not completed) to an Adverse Event (AE) that led to Patient 1's death. (Refer to A0286); and

2. The hospital leaders failed to develop and implement a preventive action plan and an effective system to timely investigate and analyze serious AEs. (Refer to A0286).

These failures resulted in the suicide of a patient (Patient 1) and contributed to an unsafe environment for patients on the C/A unit by leaving them unsupervised for extended periods of time in an environment that was inadequately assessed for immediate safety concerns.

The cumulative effects of this systemic problem resulted in the hospital's inability to maintain an effective QAPI in accordance to the statutorily and mandated Conditions of Participation for QAPI Program.

Based on observation, interview, and record review, the facility failed to analyze the extent and severity of the contributing factors (patients on the Child/Adolescent unit were not consistently monitored every 15 minutes and facility-wide, physical environment ligature [a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] -risk assessments were not completed) that lead to an adverse event, Patient 1's completed suicide death.

These failures resulted in the suicide of a patient (Patient 1) and contributed to an unsafe environment for patients on the C/A unit by leaving them unsupervised for extended periods of time in an environment that was inadequately assessed for immediate safety concerns.

The State Survey Agency (SA) determined the facility's noncompliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to patients.

On 12/20/23 at 4:03 p.m., the SA provided the CMS Immediate Jeopardy (IJ) Template to the Quality Director and Chief Executive Officer and informed them that IJ existed related to Program Activities tag A286 [42CFR 482.21 (c) (2)] and began on 12/20/23. On 12/20/23 at 7:43 p.m., the facility provided an acceptable IJ removal plan.

On 12/21/23 at 11:53 a.m., the survey team validated the facility's corrective actions and removed the IJ onsite. The facility remained out of compliance at A0144.

The hospital developed and submitted an acceptable action plan that addressed the IJ situation and the immediacy was removed on 12/20/23 at 7:43 p.m. The hospital implemented immediate corrective actions to address the issues which included:

1. The facility provided a plan for monitoring compliance of patient observation via spot check of video surveillance footage on the Child/Adolescent (C/A) Unit during the night shift.

2. Facility developed "Patient Observation and Rounding Validation Process" to establish a compliance monitoring workflow and reinforce "Unit Patient rounds" policy.

3. Facility developed a plan to randomly select patients from the census list for cross-reference and confirmation of time when rounds were documented in Rover (an electronic recording system to document rounding activities of staff) as completed and time rounds were observed on video footage recording.

4. On-going audit of video footage will be done daily on varying, randomly selected two blocks of time from 11p -7a on the C/A unit during the night for 30 days until a target of 100% compliance is met. Compliance means timely rounding, directly visualizing patients during rounds, and accurate documentation.

5. After the initial 30-days, on-going audit of video footage will be done two days per week on varying, randomly selected two-hour blocks of time from 11p-7a on the C/A unit during night shift for 3 months until a target of 100% compliance is met.

6. Audit will include name of reviewer, date of review, date of footage observed, time frame, documentation review notes, video observation notes, name of staff completing rounds, compliance, follow-up needed, actions taken by managers with dates.

7. Corrective action will be issued promptly for instances of non-compliance.

8. Video rounds verification were provided as evidence of rounding validation compliance for December 20, 2023 from 11 p.m. to December 21, 2023 at 7 a.m.

The survey team conducted observations, interviews, and record reviews onsite to ensure the changes took place before the IJ was removed on 12/21/23 at 11:53 a.m.

Findings:

During a review of Patient 1's "H&P (History & Physical)," dated 12/4/23, the H&P indicated Patient 1 was admitted to the facility for "self harm thoughts." The H&P further indicated Patient 1 had taken the family car and while driving had hit a barrier at an unknown speed." The H&P further indicated the patient had left a "goodbye letter in car."

During a review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 had a history of bipolar disorder (a mental health condition that causes extreme mood swings), and major depressive disorder (a mental condition characterized by a persistently depressed mood often with symptoms such as suicidal thoughts) with several suicide attempts. The admission note further indicated Patient 1's risk factors included multiple past suicide attempts by various methods including hanging, overdose, and jumping from a bridge.

During a continued review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 was a danger to self due to a mental health disorder. The admission note indicated Patient 1 was to be admitted, "under observation level: Every 15 minutes."

During a review of Patient 1's clinical note (CN) by Chief Medical Executive (CME) dated on 12/6/23 at 7:13 a.m., the CN indicated Patient 1 had "completed suicide."

A concurrent observation, interview, and record review on 12/18/23 at 11:04 a.m. was conducted with the Nurse Educator (NE) and Manager of Protective Services (MPS) of the facility video surveillance of the Child/Adolescent (C/A) unit and Patient 1's medical record of safety checks or rounding documentation. NE stated it was observed that Registered Nurse (RN) 1 and RN 2 did not do rounds of patients in their rooms on 12/6/23 from 1:37 a.m. to 2:20 a.m. NE and MPS confirmed this observation. MPS stated that there was a total of 114 minutes with no evidence of staff performing observations for Patient 1 in the C/A unit. NE confirmed the next observation of Patient 1 in Room 33 was done at 2:41 a.m. on 12/6/23. NE cross referenced this observation with the documentation in Patient 1's medical record and noted that RN 1 documented Patient 1 was "sleeping, breathing" at the following times: 1:45 a.m., 2 a.m., 2:15 a.m., 2:28 a.m.

During a concurrent interview on 12/20/23 at 11:20 a.m. with the leadership team [Chief Executive Officer (CEO), Quality Director (QD), Director of Nursing (DON), Risk Officer (RO), NE, and CME] and record review of the action plans regarding the death of Patient 1, the leadership team presented the proposed action plan in place after the death of Patient 1 happened based on their root cause analysis (method of identifying the original cause of faults or problems). The RO stated that the root cause for this adverse event was the lack of observation or rounding (actual observation) by staff and the erroneous and invalid documentation in Patient 1's record to indicate staff had rounded.

During an interview on 12/21/23 at 10:50 a.m. with the QD stated that patient safety reports (PSR; reporting system for incident reports) were reviewed and discussed during leadership huddles. QD confirmed that the gaps identified in this adverse event related to the lack of monitoring had not been discussed in these huddles. QD further stated that no data had been collected to identify the extent of these gaps to ensure safety of the other patients on the C/A unit. QD also stated facility had not audited staff compliance with facility required every 15 minute patient rounding based on video surveillance.

During an interview on 12/21/23 at 12:30 p.m., with the DON and concurrent phone interview with the Unit Manager 1 (UM 1), the DON and UM 1 confirmed that the identified gap was a lack of monitoring of patients according to the facility policy. DON and UM 1 also confirmed that cross referencing the time of documentation of observations made and the video review have not been done to identify the extent of the staff failure to not physically round or observe their patients.

During a review of the policy titled, "Plan for the Provision of Care," revised on 6/8/2022, indicated, " ...monitoring and evaluation of the effectiveness of patient care ... are maintained on an ongoing basis through a well-defined program for improving organizational performance ..."

During a review of the policy titled "Unit Patient Rounds," revised on 3/12/2021, indicated, "It is the policy ...that visual and verbal (where applicable) contact is made on all patients at least every fifteen minutes to assure the safety of patients ...direct visual observation with corresponding documentation is a fundamental feature of the safe and therapeutic milieu (safe, structured environment) ..."

During review of the policy titled "2022 Performance Improvement (PI) Plan and Patient Safety (PS) Plan," dated 10/7/2022, indicated, " ...to provide collaborative, interdisciplinary team approach to improving performance across the continuum of care ...ongoing monitoring and analysis of data will be reported on a regular basis in accordance to regulatory compliance ...internal and external data are used to identify and track the frequency and type of quality and patient safety issues ..."

During a review of the policy titled, "Performance Improvement Plan (PI) and Patient Safety (PI [sic]) Program for [name of facility]" dated 7/26/2023 indicated, " ...the purpose of the PI plan is to define, implement and maintain [name of facility] effective, on-going, data driven quality assessment and performance improvement program to ensure that patient care processes ...are measured, analyzed and improved ..."

During a review of the policy titled, "Measuring and Assessing of the Performance of the Environment of Care Policy" dated 2/20/2020 indicated, " ...A performance Improvement activity shall be developed each time the date from the ICES [Information, Collection, and Evaluation System] indicates any of the following: a sentinel event has occurred ...Performance levels , patterns, or trends have varied significantly and are undesirable from those expected ...collect aggregate data and monitor performance indicators. Analyze, assess, and identify an opportunity for improvement from data collected, develop a measurable improvement activity. Implement improvement activity. Monitor data on the effectiveness of the improvement action ..."

Based on observations, interviews, medical record, document and policy review, the hospital failed to effectively organize and deliver safe, quality nursing services to patients on the Child/Adolescent (C/A) Unit as evidenced by:

A. The facility failed to ensure that a registered nurse was consistently assigned to supervise and evaluate the nursing care for a census of 8 patients on the Child/Adolescent (C/A) Unit for the night shift on 12/5/23. (Refer to A 0395);

B. The facility failed to ensure Code Blue (a cardiac or respiratory emergency necessitating emergent initiation of resuscitation) documentation was completed according to facility policy for Patient 1 on 12/6/23 and training and competency was up to date for 2 out of the 6 staff (House Supervisor 1 (HS 1) and Registered Nurse 4 (RN 4)) who responded to a Code Blue for Patient 1 on 12/6/23. (Refer to A 0397) and;

C. The facility failed to ensure C/A nursing staff adhered to facility policies and procedures (Refer to A 0398) and;

These failures put patients on the C/A unit at increased risk for poor health outcomes, injuries, adverse events and death. These failures contributed to Patient 1's death by suicide on the morning of 12/6/23.

The cumulative effect of these failures resulted in the hospital's inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.

Based on staff interviews and document review and facility policy review, the facility failed to ensure that a registered nurse was assigned to supervise and evaluate the nursing care for a census of 8 patients on the Child/Adolescent (C/A) Unit for the night shift on 12/5/23.

This failure resulted in inconsistent delegation of duties for assessment and evaluation of care for patients on the C/A Unit and resulted in the suicide of a patient (Patient 1) by leaving them unsupervised for extended periods of time.

Findings:

The December 2023 C/A Unit Nursing Assignment Sheets were reviewed. The 12/5/23 night shift (night shift started on 12/5/23 at 11 pm and ended 12/6/23 at 7 a.m.) Nurse Assignment Sheet was missing.

In an interview on 12/18/23 at 11:30 a.m., the Nurse Educator (NE) admitted no patient care assignments were documented for the night shift on 12/5/23.

During a group interview with facility leadership on 12/19/23 at 11:40 a.m., the Quality Director (QD) acknowledged unit assignment sheets on the C/A Unit were not being completed consistently.

During an interview on 12/19/23 at 3:30 p.m., Registered Nurse 1 (RN 1) stated she was the charge nurse on the Child/Adolescent Unit the night of 12/5/23. RN 1 stated she was assigned to patients in "Hallway 1" and the other registered nurse (RN 2) was assigned to patients in "Hallway 2". RN 1 explained there were 8 patients, so "the patients were divided between us evenly." When asked if she completed a unit Nursing Assignment Sheet for 12/5/23 night shift, RN 1 responded, "Yea, I think I did."

During a group interview on 12/21/23 at 12:32 p.m., the Unit Manager 1 (UM 1) for the C/A Unit stated a Nursing Assignment Sheet for the night of 12/5/23 (night shift) was missing. UM 1 explained that it was "never turned in" and the House Supervisor (HS 1) never received one from the Child/Adolescent Unit staff either. "I'm assuming it wasn't completed," UM 1 concluded.

According to facility 12/14/20 policy titled, "Patient Care Assignments," "It is the policy of [the hospital] nursing department to assign patient care to the nursing staff based on each discipline scope of practice and training. Patient Care Assignments will be based on the patient's assessment category... An RN will retain responsibility for each patient...Unit Assignment sheets will reflect Patient Care Assignments..." Per policy, the assignment sheet is to be completed by the charge nurse at the beginning of the shift, retained and archived.

Based on interviews, personnel file review, and facility policy review, the facility failed to ensure:

1. Code Blue (a cardiac or respiratory emergency necessitating emergent initiation of resuscitation) documentation was completed according to facility policy for Patient 1 on 12/6/23; and

2. Training and competency was up to date for 2 out of the 6 staff (House Supervisor 1 (HS 1) and Registered Nurse 4 (RN 4)) who responded to a Code Blue for Patient 1 on 12/6/23.

This failure had the potential to put Child/Adolescent (C/A) unit patients at risk of prolonged and/or inadequate Code Blue response and had the potential to contribute to Patient 1's death.

Findings:

1. A review of Patient 1's medical record revealed Code Blue documentation limited to only a Progress Note entered 12/6/23 at 4:54 a.m., "[Patient 1] found in her room hanging and unconscious at around 0245. EMS was activated, Code Blue was called, CPR started for about 10-15 mins before EMS arrived. EMS took over, then after a while EMS announced [Patient 1] passed."

During an interview with the Risk Officer (RO) on 12/18/23 at 2 p.m., RO confirmed that neither a Code Blue flow sheet nor narrative notes were completed for Patient 1's code blue on 12/6/23.

According to facility policy titled, "CPR", dated 4/4/19, it directed, "... Documentation during a Code Blue should occur concurrently. Documentation should include: a. Time incident occurred. b. First responder. c. How arrest was recognized/time CPR was started. d. Time code called. e. Vital Signs [and] f. Time medical control was relinquished to paramedic team and disposition of patient."

The facility "Code Blue" policy, dated 7/13/20, was reviewed. The policy read, "the designated nursing supervisor or designee shall record all "Code Blue" data in the progress notes."

2. During a concurrent video recording observation and interview on 12/18/23 at 11:50 a.m., the Nurse Educator (NE) identified that both HS 1 and RN 4 responded to the Code Blue for Patient 1 on 12/6/23. During the interview, NE explained, "Code Blues are discussed at new employee orientation and annual skills day," and the facility did not conduct "mock codes [Code Blue drills]". NE stated no one is assigned a specific task before or during a Code Blue. When asked if the facility assigned staff to bring specific emergency supplies to a code, NE stated, "No".

A review of six personnel files for Code Blue training and competency validation revealed 2 of the 6 staff (RN 4 and HS 1) were overdue for Code Blue training and competency validation. RN 4's most recent Code Blue training and competency validation was 11/04/21 during the Nursing Department's "2021 Annual Competencies for Behavioral Health (BH)". The review of HS 1's personnel file showed HS completed "CPR/Code Blue" competency on 7/12/22 during a "[Facility] Central Intake Orientation and Competencies."

During an interview with Registered Nurse 1 (RN 1) on 12/19/23 at 3:30 p.m., RN 1 stated "random" Code Blue topics (i.e. how to announce a Code Blue) were addressed only once a year at the Skills Fair. RN 1 stated she never participated in a Code Blue drill or exercise at the facility.

During a concurrent observation and interview on 12/21/23 at 9:15 a.m. with Registered Nurse 6 (RN 6), RN 6 was asked to demonstrate attaching the ambu bag to the oxygen tank. RN 6 stated, "I don't do this often, so I will ask someone who knows how to do this."

During a concurrent observation and interview on 12/21/23 at 9:56 a.m. with Unit Manager 2 (UM 2) and House Supervisor 2 (HS 2), it was observed that the oxygen tank regulator knob was broken. UM 2 and HS 2 confirmed this observation. UM 2 and HS 2 stated that oxygen tanks are checked everyday and recorded in the "Emergency Supply Sheet (ESS)." It was also observed that there are no entry in the ESS from December 1 to 13, 2023. UM 2 and HS 2 confirmed this and that the first entry on the ESS started on Dec 14 indicating the oxygen regulator knob was broken and that the UM was notified.

During an interview with the Quality Director (QD) on 12/19/23 at 5 p.m., QD stated the facility did not conduct Code Blue drills/exercises.

In a group interview with the Director of Nursing (DON) and C/A Unit Manager 1 (UM 1) on 12/21/23 at 1 p.m., the DON expected all direct care staff to be competent in Code Blue procedures and perform "return demonstrations" to validate competency. The DON stated staff Code Blue training and competency validation was required upon orientation and annually.

During a group interview with Leadership on 12/19/23 at noon, the Chief Medical Executive (CME) and Chief Executive Officer (CEO) were asked about physician involvement in the facility-established Code Blue policies and emergency equipment. Neither the CME nor CEO provided comment or an answer.

According to the 5/7/21 facility policy titled, "Nursing Standards of Care," it stipulated, "Patients can expect that nursing involved in the delivery of their care are competent and that plans for training and development for staff are derived from patient care clinical demands...[and] nursing staff maintain acceptable level of competency upon annual review."

According to facility 4/4/19 policy titled, "CPR", "1. The first staff member on the scene has the responsibility for: i. Assessing the patient and determining unresponsiveness. ii. Announce Code Blue. Instruct help to announce: "Code Blue" and location 3 times over the emergency notification system, then to call 9-911. iii. First responder will then check victim for a pulse on the carotid artery and observe for any signs of breathing. If pulse is not present, begin cardiac compressions in accordance with the American Heart Association Guidelines for CPR...2. The other responders on the scene will: i. Arrive on scene with AED and Barrier Device (i.e. Ambu-Bag or pocket mask)...3. The third staff on the scene has the responsibility for getting patient's name and vital information.."

According to the 7/13/20 facility policy titled "Code Blue", "All direct care staff members are trained in Cardiopulmonary Resuscitation (CPR) techniques and can assume the responsibilities of initiating CPR...The policy also indicated all direct care staff are required to have an active/valid Health Care Provider BCLS CPR card and "the BCLS instructors will evaluate the staff response, performance and adherence to the CPR procedure/protocol/techniques. The evaluations will be used to review with the staff their level of competence and to identify areas for improvement and staff development to achieve and maintain required level of CPR competency." No unit-specific Code Blue orientation or training was mentioned in the policy.

Based on observation, interview, and record review, the facility failed to ensure nursing staff adhered to facility policies and procedures for patients on the Child/Adolescent (C/A) when:

1. Patients on the C/A unit were not consistently monitored every 15 minutes according to facility policy on 6 of 6 selected dates; and

2. An environment of care "Shift-to-Shift Checklist" in accordance with facility policy was not completed on the 12/5/23 night shift.

These failures put all unsupervised patients on the C/A unit at risk for harm without facility required supervision in an inadequately assessed environment, and resulted in the suicide of a patient (Patient 1).


Findings:

1. Patients on the C/A unit were not consistently monitored every 15 minutes according to facility policy on 6 of 6 selected dates.

During a review of Patient 1's "H&P [History & Physical]," dated 12/4/23, the H&P indicated Patient 1 was admitted to the facility for "self harm thoughts." The H&P further indicated Patient 1 had taken the family car and "while driving had hit a barrier at an unknown speed." The H&P further indicated the patient had left a "goodbye letter in car."

During a review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 had a history of bipolar disorder (a mental health condition that causes extreme mood swings), and major depressive disorder (a mental condition characterized by a persistently depressed mood often with symptoms such as suicidal thoughts) with several suicide attempts. The admission note further indicated Patient 1's risk factors included multiple past suicide attempts by various methods including hanging, overdose, and jumping from a bridge.

During a continued review of Patient 1's "Inpatient Admission Note," dated 12/4/23, the admission note indicated Patient 1 was a danger to self due to a mental health disorder. The admission note indicated Patient 1 was to be admitted, "under observation level: Every 15 minutes."

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. with the Chief Executive Officer (CEO) and the Nurse Educator (NE) of room 33 (Patient 1's former room) on the C/A unit, the CEO stated, "Patient rooms are ligature [a point or structure which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] resistant, not ligature free, and that is why we do rounds [observations of patients]." The NE stated during patient rounding, staff need to go into the patient room to check on the patient and if a patient was identified as a higher risk, their levels of observation would be increased.

During a concurrent observation and interview on 12/18/23 at 11:10 a.m. with Manager for Protective Services (MPS) and NE, video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. The video footage indicated two individuals walking in the hallway, entering patient rooms and then walking back down the hallway out of camera frame. The NE stated the two individuals were staff members conducting what appeared to be shift-to-shift handoff rounds at the 12/5/23 11:20 p.m. time stamp. The NE stated the video further indicated a staff member looking in Patient 1's room and other patient rooms (conducting patient rounds) in the C/A unit hallway at the 12/5/23 11:42 a.m., and 12/6/23 12:01 a.m., and 12:14 a.m. timestamps. The NE stated the expectation was for staff to document patient rounds in real time, to mean the time the staff physically checked on the patient would reflect the time the rounds were documented in each patient's clinical record.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 12:22 a.m., the note indicated Patient 1 was observed "lying in bed resting facing away from door, continue to monitor every 15 minutes ATC [Around The Clock] by floor staff for safety." The note further indicated Patient 1's level of observation was every 15 minutes, and "Self Harm Precautions" were listed as "every 15 minute checks."

During a continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. The NE stated the video indicated a staff member looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:23 a.m. timestamp.

During a continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. The NE confirmed the video indicated a staff member looking in Patient 1's room and other patient rooms in the C/A unit hallway at the 12/6/23 12:47 a.m. time stamp.

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room was viewed. MPS stated the next time on video footage a staff member was observed conducting rounds in patient rooms was at the 12/6/23 1:00 a.m., 1:18 a.m., and 1:32 a.m. timestamps. NE stated it appeared Patient 1's room was "skipped" at those times.

During continued concurrent observation and interview on 12/18/23 at 11:10 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room was viewed. MPS stated the video footage of the C/A unit hallway outside of Patient 1's room indicated a time leap from 12/6/23 at 1:37 a.m. to 2:20 a.m., to mean no activity from staff or any other person was recorded or had taken place in the hallway, such as patient rounds in any patient room, for that 43-minute time-period.

During concurrent observation and interview on 12/18/23 at 11:40 a.m. with MPS and NE, video footage of the C/A unit hallway outside of Patient 1's room was viewed. MPS stated the next observed time a staff member conducted rounds in Patient 1's room was not until 12/6/23 at 2:41 a.m. MPS stated according to the video footage, it was approximately 114 minutes before a staff member conducted an additional safety check on Patient 1.

During concurrent observation and interview on 12/18/23 at 11:40 a.m. with MPS and NE video footage of the C/A unit hallway outside of Patient 1's room during the night of 12/5/23-12/6/23 was viewed. NE stated a staff member was observed entering Patient 1's room at the 12/6/23 2:41 a.m. timestamp. The video footage indicated about a minute later, at the 2:42 a.m. timestamp, an additional staff member was observed running into Patient 1's room.

During a review of Patient 1's "Behavioral Health Note," dated 12/6/23 at 4:46 a.m., the note indicated Patient 1 was found in her room hanging and unconscious at around 2:45 a.m. that morning. The note further indicated CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating) was started for about 10-15 minutes before EMS (Emergency medical services, also known as ambulance services or paramedic services) arrived, "then after a while EMS announced pt [patient] passed. Police arrived with coroners [an official who investigates violent, sudden, or suspicious deaths] office [name of coroner] and pt was taken."

During an interview on 12/19/23 at 10:25 a.m. with Registered Nurse (RN) 3, RN 3 stated all patients on the C/A unit are on q (every) 15 minute checks, or observations, unless a more frequent observation level is noted in a physician order. RN 3 stated the expectation with patient rounds was to lay eyes on each patient to ensure they were safe.

During an interview on 12/19/23 at 11:40 a.m. with Risk Officer (RO) and the Quality Director (QD), the RO stated during the time staff did not round on Patient 1, the patient had time to accomplish her suicide. The RO stated rounds were documented in Patient 1's clinical record but not completed based on the video of the C/A unit hallway. The QD stated ligature risk is mitigated by increasing observation of the patients.

During a concurrent observation and interview on 12/20/23 at 10:22 a.m. with RO, additional camera footage of five additional dates of the C/A unit patient room hallway, were reviewed. RO stated for dates 11/14/23 between 3:21 a.m. and 4:08 a.m. (approximately 47 minutes); 11/17/23 between 4:21 a.m. and 5:12 a.m. (approximately 51 minutes); 11/30/23 between 4:42 a.m. and 5:59 a.m. (approximately one hour and seven minutes); 12/3/23 between 3:26 a.m. and 4:14 a.m. (approximately 48 minutes), and then again between 4:55 a.m. and 5:52 a.m. (an additional approximate 57 minutes); and 12/4/23 between 4:34 a.m. and 5:32 a.m. (approximately 58 minutes); the camera footage indicated no staff or patient activity was observed in the hallway (such as patient rounds). RO stated the camera footage indicated patient rounding was being conducted "more like hourly" and not every 15 minutes per facility requirement.

During an interview on 12/21/23 at 12:45 p.m. with the Director of Nursing (DON) and Unit Manager (UM) 1, UM 1 stated the expectation for patient rounds was staff were to physically lay eyes on the patients to document location and activity. UM 1 stated if patients were asleep, staff were to ensure the patient was breathing by observing the rise and fall of the chest. UM 1 further stated prior to the death of Patient 1, she was not aware patient rounding was not being done, and the expectation was documentation of rounding should be in real time. UM 1 stated, "everybody knows rounds should be done" and "anyone and everyone can do rounds." UM 1 further stated patient rounds are done to ensure the safety of patients and to ensure they do not harm themselves.

During a review of a facility P&P titled, "Precaution and Observation Levels based on Patient Assessment," dated 1/15/2021, the P&P further indicated, "All patients are observed at a minimum every 15 minutes for the entire admission." The policy further indicated, "Rounding on patient includes: patient location, patient activity/behavior, observation of patient breathing/respirations by observing rise and fall of the chest as an example, that patient has no signs of distress and the environment the patient is in is safe."

During a review of the facility's policy and procedure (P&P) titled, "Unit Patient Rounds," dated 3/12/2021, the P&P indicated, "It is the policy at [name of facility] that visual and verbal (where applicable) contact is made on all patients at least every fifteen minutes to assure the safety of patients and staff." The policy further indicated, "Direct visual observation with corresponding documentation is a fundamental feature of the safe and therapeutic milieu at [name of facility]." The policy further indicated, "The patient whereabouts are documented every fifteen minutes as directly visualized by the staff member assigned to conduct rounds."


2. An environment of care, "Shift-to-Shift Checklist", was not completed on the 12/5/23 night shift.

During a concurrent observation and interview on 12/18/23 at 9:45 a.m. with NE and CEO in room 33 (Patient 1's former room) on the C/A unit, a metal track was observed affixed to the top of a door frame to the bathroom. The metal track contained white clips that were able to slide back and forth along the track. The NE stated the clips were meant to hold a privacy curtain to the bathroom, should a patient request one. Further observations of the bathroom revealed a shower stall with a shower curtain, curtain clips and a track. The shower curtain was observed suspended from only one shower clip. The remaining clips were observed attached to the shower curtain and the track.

Additional items observed in room 33 on the C/A unit included: patient clothing stored in bedside shelves, a paper bag on the floor with various items of patient clothing (including a bra), and petroleum jelly in a medicine cup on the bedside table.

In a concurrent interview on 12/18/23 at 9:45 a.m, the CEO and NE were asked if the patient rooms were routinely assessed for safety, e.g., ligature risks and they said "shift-to-shift rounds" were completed.

Observations of patient room 32 on the C/A unit were conducted with NE on 12/18/23 at 10 a.m. No privacy curtain, curtain clips or track were observed in the bathroom door frame of room 32. A shower curtain (made of a thick, heavy fabric) was observed just outside the shower stall in the bathroom, hanging from fabric tags with Velcro. The Velcro tabs were secured to a curtain track. Additional items observed in room 32 included a jacket with a metal zipper and a set of headphones.

During observations of patient room 35 on the C/A unit on 12/18/23 at 10:05 a.m., a privacy curtain was observed hanging from white curtain clips and secured to a curtain track in the bathroom door frame. Inside the bathroom, a shower stall was observed with a shower curtain suspended from white clips and track.

During a concurrent observation and interview on 12/18/23 at 10:20 a.m. of the metal track affixed to the top of the door frame to the bathroom in room 33 on the C/A unit with the NE and CEO, the Department was able to thread a bedsheet through the track, over the plastic clips, and bear weight on the sheet as if to hang from it. Both the CEO and the NE acknowledged the immediate ligature safety concern and the metal tracks/clips would be removed from all patient rooms "today."

On 12/18/23, the Department requested the facility provide documented evidence that shift-to-shift environmental rounds were completed on the C/A Unit between September and December 2023.

On 12/19/23, the facility provided the Department with three "Shift-to-Shift Checklists" completed by staff from the C/A Unit. They were dated: 8/31/23, 9/3/23 and 12/18/23. The facility did not provide a C/A Unit "Shift-to-Shift Checklist" from 12/5/23. No other "Shift-to-shift" Checklists" were provided.

From a review of the three completed C/A Unit "Shift-to-Shift Checklists" (checklist last revised 1/3/19), staff used the checklists to direct their unit environmental rounds. The staff documented using "check marks" to indicate that specific areas on the unit were observed and met environmental safety "compliance expectations". More specifically, the 8/31/23, 9/3/23 and 12/18/23 checklists reflected only three days patient rooms were assessed to be: "Floors clear of clothes and linen. No food stored in room. No extra linen in cubby. Appropriate chair in room. 1 trash can in room. Shower curtain present. Base board intact. [and] All in good working order."

During a group interview with facility leadership on 12/19/23 at 11:50 a.m., the question was asked if, prior to 12/5/23, the privacy curtains, shower curtains, clips or tracks were identified as unsafe, a ligature-risk, or unsuitable for patients at risk of suicide. The CEO explained the facility has a policy that high risk patients must be observed, mitigating the potential use of those items for self-harm. The Quality Director (QD) acknowledged shift-to-shift environment of care unit rounds on the C/A Unit had not been completed consistently.

According to a 3/12/21 facility policy titled, "Shift to Shift Rounds," "Immediately following change of shift report, one member of the incoming shift and one member of the off-going shift is assigned to conduct unit rounds."
The facility policy titled, "Identification of Patients at Risk for Suicide," dated 6/6/2019, indicated that the immediate safety needs and most appropriate treatment setting for each patient should be evaluated upon admission and throughout the patient's hospital stay. Environmental factors and features may increase a patient's risk for suicide, such as access to contraband and other lethal means of suicide. Environmental precautions are taken for all inpatients at [the facility].

During an interview with the DON and C/A UM 1 on 12/21/23 at 1 p.m., UM 1 explained shift-to-shift rounds were equivalent to an environmental shift-to-shift "hand-off". UM 1 explained the importance of the environmental rounds for patient safety; the checklists assist with staff awareness of items in the patient's room that may increase a patient's risk for self-harm. Room assessments can be completed as needed too, to eliminate environmental risk to patients, UM 1 added. UM 1 acknowledged an environmental "Shift-to-Shift Checklist" from 12/5/23 was missing.