HospitalInspections.org

*Amended September 21, 2023...

Based on facility staff interviews, review of staffing schedule, rounding check list, facility quality improvement documents, accreditation organization survey review, observation of ligature risks on doors, and medical record review, the facility failed to ensure a safe environment for patient care and failed to protect a patient from neglect resulting in self-harm for one (1) of one (1) patient: Patient #1

Findings Include:

Observation of photographs of Patient #1's door (#22), Building 203, Ward 4 on 08/22/2023 confirmed the door handles and door hinges for the patient room entrance *were not ligature resistant. The wooden doors had metal lever handles and piano hinges with a bolt latch assembly which anchors into a hole in the door facing keeping the door shut and allowing it to be used for leverage with the use of a ligature item.

Interview on 08/30/2023 at 10:17 A.M. with the *Accreditation and Licensure Director (ALD) confirmed bids were obtained in 2021 for the replacement of the ligature risks on the patient's doors. Bids were accepted in the year 2021, but were not approved due to the lack of funding. New Bids were recently submitted and on 08/01/2023 and was awarded to a bidder.

An interview was conducted on 08/30/2023 at 11:00 a.m. with the Assistant Director for Behavioral Health Services and the Director of Behavioral Health Services, confirmed the Columbia Suicide Severity Rating Scale completed on Patient #1's admission on 06/30/2023, only triggered a patient safety plan. They further confirmed a staff reported behavior by Patient #1 triggered another Columbia Suicide assessment on 7/14/2023 which triggered a Comprehensive Suicide Assessment which was completed 7/18/2023 and subsequent Collaborative Assessment and Management of Suicidality (CAMS) suicide status assessments with the last three being on 7/24/23, 7/25/23 and 7/26/23 which rated the patient a low risk and along with no reported ideations and behaviors patient was discontinued from suicide precaution level to routine observations on 07/31/2023.

Interview with the facility Accreditation and Licensure Director (ALD) on 08/29/2023 at 11:40 p.m. confirmed there were no Direct Care Staff (DCS) workers in Patient #1's acute hall of building 203, Ward 4 at the time of the incident on 08/22/2023 around 5:00 p.m. The ALD stated, " ...the DCS workers left the acute hall to retrieve the dinner trays at the opposite side of the building and due to a covid outbreak the doors dividing acute hall from rest of building was closed and locked and therefore blocked the view from distal hall containing nursing station from the acute hall ...".

Interview with the Assistant Director for Behavioral Health Services on 08/30/2023 at 11:45 a.m. confirms Patient #1's medical record did not have documented evidence of a safety plan, which should have been developed and documented within 3 business days of admission.

Review of the staffing report in the facility's timekeeping system dated 08/22/2023 for Building 203, Ward 4, Shift B (3:00 p.m. - 11:00 p.m.) confirms four (4) DCS workers and a Ward Shift nurse were working.

Review of the facility's assignment report dated 08/22/2023 reveal no staff to patient assignments documented and no documentation of staff assigned to complete the 15-minute patient safety checks per the facility's policy.

Review of the facility's "Rounding Check Sheet," dated 08/22/2023 confirmed no documented evidence of 15-minute patient safety checks for Patient #1 after 3:15 p.m.

Review of the facility's policy, "Patient/Resident Daily Accountability and Safety," policy # 210-78, dated June 2021 confirms, " ... policy establishes procedures for patient/resident accountability and safety checks 24 hours a day and maintaining written documentation of these checks ...C. Inpatient Services (IPS) Patient Ward Safety Checks are performed every 15 minutes to account for patients and ensure a safe environment of care ...shift leader will assign one or more employees to perform patient ward safety checks ...".

Review of facility investigative document titled, "QA Review Building 203, Ward 4," dated 08/23/2023, at 3:30 p.m. reveals, " ...Events prior to the Incident ...On August 22, 2023, Patient #1 was observed, and document patient was present around 3:15 p.m. on the ward. At the beginning of the shift change for B shift (3:00 p.m. - 11:00 p.m.), only 2 direct care staff were present. Two (2) contract direct care staff workers arrived around 4:15 p.m., and another arrived around 6:15 p.m. The acuity on the ward was very high this day. One patient was on 1:1 observation with one staff member, and another patient was placed in seclusion for violent behavior and for throwing feces which required the attention of another staff member. At various times, the latter patient required the attention of two direct care staff members. When the "third" staff member was not assisting with the violent patient, he was assisting with the delivery of the evening meal on the unit. The "fourth" direct care staff member was making rounds with the resident physician. All four direct care staff members were busy with other duties, so the routine 15 - minute rounds were not performed ...".

Record review of Physicians Orders for Patient #1 confirmed patient was placed on "Special Level of Observation, suicide precautions one (1) on one (1) (1:1) observations on Shifts A, B, and C" for displaying suicidal tendencies by using a plastic spoon to self-harm on order dated 07/14/2023 at 8:23 p.m. by PMHNP #1, the order was renewed on 07/18/2023 at 3:15 p.m. by PMHNP #1, and on 07/21/2023 at 9:00 a.m. by PMHNP #1, and again on 07/25/2023 at 8:07 a.m. by PMHNP #1, Physician order dated 07/28/2023 at 10:20 p.m. by PMHNP #1 confirms Patient #1 was placed on "Special level of observation Visuals Contact all shifts, for self-injurious behavior."

Review of Patient #1's Clinical Progress note (dated 07/31/23 at 11:00 a.m.), Psychiatric Nurse Practitioner #1 revealed order to ... discontinue visual checks observation and place on routine observation. Note stated Patient #1, " ...participated in and completed three (3) CAMS and scored low on all three (3). Patient #1 also participated in integrated System of Care (ISC) with Behavioral Health Staff (BHS). At this time, Patient #1 is not at an acutely elevated risk for suicide or violence...".

Review of Patient #1's Treatment Plan, dated 07/31/2023 confirms an unscheduled review due to the discontinuation of suicide precautions with no documentation specific to suicidal precautions/interventions changes signed by Physician #1.

Review of document titled Clinical Progress Notes (date 8/22/2023) at 10:20 a.m. the Psychiatric Nurse Practitioner #1 entry reveals, " ...At this time, it's our clinical opinion Patient #1 is not at an acutely elevated risk of harm to self or others; his history of substance use may chronically predispose him to a greater risk of harm to self and others after discharge ...".

Review of facility report titled, "Investigative Findings" dated August 28, 2023, reveals, " ...Patient #1 got a chair from room #017 which is just off the dayroom on the acute hall of building 203, ward four (4) and took it to his room (#022) ...tied a knot at one end of his bedsheet and placed the knotted end in the door ...Patient #1 may have stood in the chair with the sheet around his neck and kicked the chair out from under him, hanging himself with the sheet. He was found lying on the floor behind the bedroom door with his legs tucked underneath him ...was unresponsive with a sheet around his neck and knotted on one end ...MD determined Patient #1 had no respiratory or cardiac activity ...B-Shift had a direct care staff (supervisor) on duty, but no 15-minute rounds were completed. The facility failed to provide sufficient supervision of Patient #1 as well as the other patients on the acute hall on 08/22/2023 ...".

Review of the facility policy and procedure, "Adult Psychiatric Patients' Rights," numbered POL 162-04 ATT A, dated September 2021, reveals ..." page 2 of 2 ...W. The right to be protected from ...neglect ...".

Review of the facility policy and procedure. "Rights of Patients," numbered POL 161-04, dated September 2021, reveals ..." page 7 of 13 ...B. The service/treatment plan will be provided and supervised by an adequate number of competent, qualified, and experienced professional clinical staff ...page 9 of 13 ...M ... (1) ...e ...The right to be protected from harm, abuse, neglect, and exploitation ...".

Review of accrediting organization survey report dated 10/10/18 revealed a citation at for building 203; all bedroom doors and shared bathroom doors hinges and knobs are a ligature risk. Further review of accrediting organization survey report dated 11/18/21 revealed a condition Level citation for " ...the door handles in the hallways/patient rooms are not ligature resistant type. The hinges to these rooms are not ligature resistant type. ...all bedroom doors and shared bathroom doors hinges and knobs are ligature risk ...". The facility has a current action plan for the mitigation of ligature risk planning.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on facility staff interviews, observation of photographs, review of staffing and assignment documents, investigative documents review, medical record review, and facility policy and procedure review, the facility failed to protect a vulnerable patients by providing a safe environment to prevent self-harm for one (1) of one (1) patient: Patient #1

Findings Include:

Cross reference to A-0115/482.13 for the facility's failure to ensure patient care in a safe environment to prevent self-harm.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on facility staff interviews, observation of photographs, review of staffing and assignment documents, investigative documents review, medical record review, and facility policy and procedure review, the facility failed to provide services necessary to prevent harm and ensure patients are free from neglect for one (1) of one (1) patient: Patient #1

Findings Include:

Cross reference to A-0115/482.13 for the facility's failure to ensure patient is free from neglect and care is provided to ensure patient safety.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on staff interview, medical record review, assignment report document review, rounding check sheet document review, investigative document review and facility policy review, the governing body failed to ensure expectations for providing safe care according to policy and procedure were followed for one (1) of one (1) patient.

Findings Include:

Cross refer to A-0115/482.13 for the facility's failure to ensure patient rights were met to ensure the safety of patients.

Cross refer to A-0385/482.23 for the facility's failure to provide safe delivery of care and follow facility's policy and procedures for safe and effective care.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on facility staff interviews, review of staffing and assignment documents, investigative documents review, medical record review, and facility policy and procedure review, the facility failed to provide safe and effective nursing care to ensure patients needs are safely met at all times for one (1) of one (1) patient: Patient #1

Findings Include:

Interview with the facility's Accreditation and Licensure Director (ALD) on 08/29/2023 at 11:40 p.m. confirmed there were no Direct Care Staff (DCS) workers in Patient #1's Acute Hall of Building 203, Ward 4, at the time of the incident on 08/22/2023 around 5:00 p.m. The ALD said the DCS workers left the Acute Hall to retrieve the dinner trays at the opposite side of the building and due to a covid outbreak the doors dividing Acute Hall from rest of building was closed and locked and therefore blocked the view from Distal Hall containing the Nursing Station from the Acute Hall.

Interview with the Assistant Director for Behavioral Health Services on 08/30/2023 at 11:45 a.m. confirms Patient #1's medical record did not have documented evidence of a safety plan which should have been developed and documented within three (3) business days of admission.

Review of the staffing report in the facility's timekeeping system dated 08/22/2023 for Building 203, Ward 4, Shift B (3:00 p.m. - 11:00 p.m.) confirms four (4) DCS workers and a Ward Shift nurse were working.

Review of the facility's assignment report dated 08/22/2023 reveal no staff to patient assignments documented and no staff assigned to complete the 15-minute patient safety checks.

Review of the facility's "Rounding Check Sheet," dated 08/22/2023 confirmed no documented evidence of 15-minute patient safety checks for Patient #1 after 3:15 p.m.

Review of the facility's policy, "Patient/Resident Daily Accountability and Safety," policy # 210-78, dated June 2021 confirms, " ... policy establishes procedures for patient/resident accountability and safety checks 24 hours a day and maintaining written documentation of these checks ...C. Inpatient Services (IPS) Patient Ward Safety Checks are performed every 15 minutes to account for patients and ensure a safe environment of care ...shift leader will assign one or more employees to perform patient ward safety checks ...".

Review of the facility's investigative document titled, "QA Review Building 203, Ward 4," dated 08/23/2023, at 3:30 p.m. reveals, " ...Events prior to the Incident ...On August 22, 2023, Patient #1 was observed, and document patient was present around 3:15 p.m. on the ward. At the beginning of the shift change for B shift (3:00 p.m. - 11:00 p.m.), only 2 direct care staff were present. Two contract direct care staff workers arrived around 4:15 p.m., and another arrived around 6:15 p.m. The acuity on the ward was very high this day. One patient was on 1:1 observation with one staff member, and another patient was placed in seclusion for violent behavior and for throwing feces which required the attention of another staff member. At various times, the latter patient required the attention of two direct care staff members. When the "third" staff member was not assisting with the violent patient, he was assisting with the delivery of the evening meal on the unit. The "fourth" direct care staff member was making rounds with the resident physician. All four direct care staff members were busy with other duties, so the routine 15 - minute rounds were not performed ...".

Review of the facility report titled, "Investigative Findings" dated August 28, 2023, reveals, " ...Patient #1 got a chair from room #017 which is just off the dayroom on the acute hall of building 203, ward four (4) and took it to his room (#022) ...tied a knot at one end of his bedsheet and placed the knotted end in the door ...Patient #1 may have stood in the chair with the sheet around his neck and kicked the chair out from under him, hanging himself with the sheet. He was found lying on the floor behind the bedroom door with his legs tucked underneath him ...was unresponsive with a sheet around his neck and knotted on one end ...MD determined Patient #1 had no respiratory or cardiac activity ...B-Shift had a direct care staff (supervisor) on duty, but no 15-minute rounds were completed. The facility failed to provide sufficient supervision of Patient #1 as well as the other patients on the acute hall on 08/22/2023 ...".

Record review of Physicians Orders for Patient #1 confirmed patient was placed on "Special Level of Observation, suicide precautions one (1) on one (1) (1:1) observations on Shifts A, B, and C" for displaying suicidal tendencies by using a plastic spoon to self-harm on order dated 07/14/2023 at 8:23 p.m. by PMHNP #1, the order was renewed on 07/18/2023 at 3:15 p.m. by PMHNP #1, and on 07/21/2023 at 9:00 a.m. by PMHNP #1, and again on 07/25/2023 at 8:07 a.m. by PMHNP #1, Physician order dated 07/28/2023 at 10:20 p.m. by PMHNP #1 confirms Patient #1 was placed on "Special level of observation Visuals Contact all shifts, for self-injurious behavior."

Review of Patient #1's Clinical Progress note (dated 07/31/23 at 11:00 a.m.), Psychiatric Nurse Practitioner #1 revealed order to ... discontinue visual checks observation and place on routine observation. Note stated Patient #1, " ...participated in and completed three (3) CAMS and scored low on all three (3). Patient #1 also participated in integrated System of Care (ISC) with Behavioral Health Staff (BHS). At this time, Patient #1 is not at an acutely elevated risk for suicide or violence...".

Review of document titled Clinical Progress Notes (date 8/22/2023) at 10:20 a.m. the Psychiatric Nurse Practitioner #1 entry reveals, " ...At this time, it's our clinical opinion Patient #1 is not at an acutely elevated risk of harm to self or others; his history of substance use may chronically predispose him to a greater risk of harm to self and others after discharge ...".

Review of the facility policy and procedure, "Adult Psychiatric Patients' Rights," numbered POL 162-04 ATT A, dated September 2021, reveals ..." page 2 of 2 ...W. The right to be protected from ...neglect ...".

Review of the facility policy and procedure, "Rights of Patients," numbered POL 161-04, dated September 2021, reveals ..." page 7 of 13 ...B. The service/treatment plan will be provided and supervised by an adequate number of competent, qualified, and experienced professional clinical staff ...page 9 of 13 ...M ... (1) ...e ...The right to be protected from harm, abuse, neglect, and exploitation ...".

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on staff interview, medical record review, staffing and assignment review, rounding check list review, investigative document review, and facility policy and procedure review, the facility's nursing staff failed to provide daily accountability and safety checks every 15 minutes on patients based on the facility's policy for one (1) of one (1) patient: Patient #1

Findings Include:

Cross reference to A-0385/482.23 for the facility's failure to ensure daily accountability and safety checks are completed every 15 minutes to ensure patient safety.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on staff interview, medical record review, assignment report document review, rounding check sheet document review, investigative document review, and facility policy review, the facility failed to adhere to the facility's policy for "Daily Accountability and Safety Checks" for one (1) of one (1) patient: Patient #1

Findings Include:

Cross refer to A-0385/482.23 for the facility's failure to adhere to policies and procedures to ensure the safety of its patients.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.

Based on staff interview, medical record review, and facility policy and procedure review, the facility's staff failed complete a patient safety plan based the Columbia Suicide Severity Rating Scale score for one (1) of one (1) patients: Patient #1

Findings Include:

An interview was conducted on 08/30/2023 at 11:00 a.m. with the Assistant Director for Behavioral Health Services and the Director of Behavioral Health Services, confirmed the Columbia Suicide Severity Rating Scale completed on Patient #1's admission on 06/30/2023, triggered a patient safety plan. A staff reported behavior by Patient #1 triggered another Columbia Suicide assessment on 7/14/2023 which triggered a Comprehensive Suicide Assessment which was completed 7/18/2023 and subsequent Collaborative Assessment and Management of Suicidality (CAMS) suicide status assessments with the last three being on 7/24/23, 7/25/23 and 7/26/23 which rated the patient a low risk and along with no reported ideations and behaviors patient was discontinued from suicide precaution level to routine observations on 07/31/2023.

Interview with the Assistant Director for Behavioral Health Services on 08/30/2023 at 11:45 a.m. confirms Patient #1's medical record did not have documented evidence of a safety plan, which should have been developed and documented within three (3) business days of admission.

Review of the facility policy and procedure numbered BHS POL 270-18, titled "Suicide Risk Suicide Risk Intervention and Treatment Planning," "... (1) All patients who report or for whom collateral evidence indicates recent suicidal thoughts or history of suicidal behaviors ...on the CSSRS-SV or during the course of treatment ...will work with BHS staff to develop a personal safety plan in a format approved by the BHS department...a. A safety Plan for use while in the hospital should be developed within 3 business days of admission. b. The Safety Plan should be reviewed and revised as needed during the course of stay in addition to a final review and revision for use outside of the hospital prior to discharge.

Review of Patient #1's medical record confirmed no documented evidence of a safety plan developed, which was triggered by the Columbia Suicide Severity Rating Scale on 06/30/2023 admission.

During the exit conference on 08/30/2023 at 3:45 p.m. with ADL Director, Nurse Educator, Safety and Investigative services, RN Director and In-Patient Services Director survey findings related to the alleged complaint were discussed. No further documentation was provided during review during exit conference.