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Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights by failing to ensure 2 (#1, #5) of 5 (#1-#5) sampled patients had the right to receive care in a safe setting as evidenced by:
1) failing to ensure that Patient #1 was observed per ordered 1:1 observations at all times. As a result, Patient #1 went into a staff bathroom alone and cut himself with glass from a light bulb and also swallowed part of the light bulb, requiring transfer to a hospital; and
2) failing to ensure that ordered LOS observations were implemented for Patient #5, who had an admission diagnosis of suicidal ideations.
(See findings under Tag A0144)

An Immediate jeopardy situation was identified on 09/05/2023 at 3:45 p.m. and reported to S5Adm. The Immediate Jeopardy was the result of the staff failing to implement ordered observation levels. This resulted in Patient #1 swallowing glass from a light bulb, sustaining injury and currently admitted to the hospital. All patients who are ordered increased observation levels of 1:1 or LOS are at risk for serious injury, harm, impairment or death due to this failure.

On 09/07/2023 at 10:40 a.m., S1Compliance presented the plan for lifting the immediacy of the IJ situation and the plan included the following:
1. The nurse on the shift will be responsible for assigning patient observation levels/precautions using the following procedure: The nurse will verify the ordered observation/precaution levels with the order written in the patients' medical record. The nurse on the 7p-7a shift will print the BHT observation logs for the following 24 hour period. The nurse will assign each patient's observation/precaution level to the BHTs by indicating the observation/precaution ordered on the BHT observation log.
2. The RN will complete and sign the shift assignment, assigning levels of observation and other tasks to qualified staff members.
3. The DON or designee will verify and document 100% of patient observation levels ordered, and that assignments are completed and signed by RNs every shift
4. The RN will conduct rounds at least every 4 hours during the 12 hour shift to assure the ordered observation/precaution levels are being conducted as ordered and will indicate compliance by initialing the observation logs.
5. All nurses will receive training related to assigning patient observation/precaution levels and will be directly observed performing these skills.
6. All nursing staff members (RN, LPN, BHT) will receive training related to conducting patient observation levels.
7. No staff member will be assigned to a patient on LOS or 1:1 observation level until they have completed training.
8. The RN is the only staff member allowed to contact the provider and receive orders for patient observation and precaution levels.
9. Nurses will alter observation levels if changed orders are received during the 24 hour period.
10. All nurses will have access to training logs that indicate staff members that have completed training. If BHTs are on duty that have not had training, LPNs and RNs will be utilized.
11. Training of all nursing staff members has commenced as of 09/06/2023 and will continue throughout the week, capturing every shift. All training is mandatory. If a nursing staff member has not completed training by 09/15/2023, they will not be allowed to provide patient care.

On 09/07/2023 at 10:40 a.m., the IJ was lifted.

Based on observation, record review and interview, the hospital failed to ensure 2 (#1, #5) of 5 (#1-#5) sampled patients had the right to receive care in a safe setting as evidenced by:
1) Failing to ensure that Patient #1 was observed per ordered 1:1 observations at all times. As a result, Patient #1 went into a staff bathroom alone and cut himself with glass from a light bulb and also swallowed part of the light bulb, requiring transfer to a hospital; and
2) Failing to ensure that ordered LOS observations were implemented for Patient #5, who had an admission diagnosis of suicidal ideations.
Findings:

Review of the policy for Level of Observations revealed in part that Line of Sight observations is defined as maintaining visual observations of patients at all times. A staff member of the same gender should be available to accompany a patient using bathroom or shower facilities, whenever possible. The staff member assigned to Line of Sight is continuously observing for signs of life, location and activity.
One-to-One observation (1:1) is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. Close proximity is to be maintained in that the staff member must never be separated from the assigned patient by a barrier such as a closed door or window.

1) Failing to ensure that Patient #1 was observed per ordered 1:1 observations at all times. As a result, Patient #1 went into a staff bathroom alone and cut himself with glass from a light bulb and also swallowed part of the light bulb, requiring transfer to a hospital.

Review of Patient #1's medical record revealed the 17 year old patient was admitted to this hospital on a PEC on 06/13/2023 after a three day history of suicidal and homicidal thoughts. Review of the psychiatric evaluation dated 06/15/2023 revealed diagnoses including suicidal ideation and major depressive disorder.

Review of an Abuse/Neglect Initial Report dated 06/29/2023 revealed that the patient obtained a light bulb from his bathroom and cut his forearms and swallowed some of the broken glass. The report stated that the patient revealed that "I started preparing for this since I first got here." The patient was transferred to the emergency department and returned that same day with orders for 1:1 observations.

Review of Patient #1's medical record revealed that upon return from the ED on 06/29/2023, the patient's observation status changed between 1:1 observation, LOS and every 15 minute observation levels multiple times over several weeks.
On 08/17/2023, Patient #1's observation level was again changed to 1:1 observations at all times.

Review of an Abuse/Neglect Initial Report dated 08/26/2023 revealed that the patient entered the staff bathroom alone in the day room and obtained a light bulb from the bathroom. Patient #1 then began to cut himself with the broken light bulb and swallowed some of the glass. The report further stated that the patient had ordered 1:1 observation level at the time of the incident, but it was not being implemented by the assigned tech, S4BHT. The patient was transferred to the emergency department and admitted to the hospital.

On 09/05/2023 at 9:00 a.m., S1Compliance confirmed that Patient #1 was not being observed at the ordered observation level (1:1) at the time of the incident on 08/26/2023. S1Compliance was asked if the hospital had performed any increased monitoring or implemented a QAPI plan to address the adherence of ordered observation levels and he stated no. S1Compliance stated that the tech involved in the incident with Patient #1 on 08/26/2023 was re-educated on observation levels, but he was unable to locate documented evidence of this. On 09/05/2023 at 3:45 p.m., no documented evidence of re-education to any staff regarding observation levels had been provided to the surveyor.

2) Failing to ensure that ordered LOS observations were implemented for Patient #5, who had an admission diagnosis of suicidal ideations.

Review of Patient #5's medical record revealed the 14 year old patient was admitted to this hospital 05/18/2023 on a PEC with suicidal ideations with a plan to cut herself.

Review of an incident report dated 06/04/2023 revealed the patient was found with a broken sharpened toothbrush and had wrapped clothing around her neck. The report also stated the patient had broken a mirror in her room and attempted to cut herself. Two male staff members assisted in getting the broken glass away from the patient.

Review of Patient #5's record revealed that after the above incident on 06/04/2023, the patient's observation status changed between 1:1 observation, LOS and every 15 minute observation levels multiple times.
On 07/31/2023, the patient's observation level was again changed to LOS observations at all times.

Review of the patient's Observation Logs from 07/31/2023 until 08/31/2023 (current) revealed the observation level was checked as every 15 minute observations.

On 08/31/2023 at 2:45 p.m., interview with S2BHT revealed she was assigned to Patient #5. When asked observation level for the patient, S2BHT stated that the patient was on every 15 minute observations. Review of the observation log dated 08/31/2023, with S2BHT, revealed the observation level checked was for every 15 minute observations.

On 08/31/2023 at 2:55 p.m., interview with S3RN revealed that based on current physician orders, Patient #5 should be on LOS observations. S3RN stated that the RN on the night shift completes the assignment sheets with the observation status noted and gives to the techs to complete for the day. S3RN further revealed that the RN initials the observation logs every two hours to confirm observations are documented and the staff is observing the patients at correct observation levels. S3RN reviewed Patient #5's observation sheet dated 08/31/2023 and confirmed the patient was not being observed at the correct observation level.

Based on record review and interview, the hospital failed to ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan after a patient (Patient #1) was not observed per ordered observation level of 1:1 and swallowed glass from a light bulb and was admitted to the hospital.
Findings:

Review of the medical record for Patient #1 revealed the 17 year old patient was admitted to this hospital on a PEC on 06/13/2023 after a three day history of suicidal and homicidal thoughts. Review of the psychiatric evaluation dated 06/15/2023 revealed diagnoses including suicidal ideation and major depressive disorder.

Review of an Abuse/Neglect Initial Report dated 06/29/2023 revealed that the patient obtained a light bulb from his bathroom and cut his forearms and swallowed some of the broken glass. The report stated that the patient revealed that "I started preparing for this since I first got here." The patient was transferred to the emergency department and returned that same day with orders for 1:1 observations.

Review of Patient #1's medical record revealed that upon return from the ED on 06/29/2023, the patient's observation status changed between 1:1 observation, LOS and every 15 minute observation levels multiple times over several weeks.
On 08/17/2023, Patient #1's observation level was again changed to 1:1 observations at all times.

Review of an Abuse/Neglect Initial Report dated 08/26/2023 revealed that the patient entered the staff bathroom alone in the day room and obtained a light bulb from the bathroom. Patient #1 then began to cut himself with the broken light bulb and swallowed some of the glass. The report further stated that the patient had ordered 1:1 observation level at the time of the incident, but it was not being implemented by the assigned tech, S4BHT. The patient was transferred to the emergency department and remains in the hospital as of 09/05/2023.

On 09/05/2023 at 9:00 a.m., S1Compliance confirmed that Patient #1 was not being observed at the ordered observation level (1:1) at the time of the incident on 08/26/2023. S1Compliance was asked if the hospital had performed any increased monitoring or implemented a QAPI plan to address the adherence of ordered observation levels and he stated no.