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Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure the implementation of safety standards for patients at risk for self-harm in adherence with hospital policy, law and regulation.

Findings include:

1. The facility failed to ensure that ligature risks are mitigated on the Crisis Emergency Department (ED) Unit and on the Inpatient Psychiatric Unit (IPU). (Cross refer to Tag A-144).

2. The facility failed to provide adequate supervision to ensure patient safety and well-being during one-to-one (1:1) care in adherence with hospital policy, law and regulation. (Cross refer to Tag A-144).

3. The facility failed to adhere to Suicide Risk Assessment and Homicide Risk Assessment measures to ensure a patient's safety and well being in accordance with hospital policy, law and regulation. (Cross refer to Tag A-144).

A. Based on observation, staff interviews, review of facility policies and documents, and review of four (4) of ten (10) medical records, it was determined that the facility failed to ensure that the care of suicidal patients was provided in adherence with hospital policy, law and regulation.


Findings include:

Reference #1: Facility policy, "Suicidal Patient Risk Assessment" states, " ... IV. Policy... 1. Patients who present to the hospital are assessed for suicide or homicide risk. ... 2. Patients identified at risk for suicide or homicide will be protected by having their immediate safety needs met by the most appropriate action(s) based on the setting. ... V. Procedure ... a. Emergency Department Triage/Assessment ... i. At triage, the registered nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Assessment Screener Version ...d. In-Patient Psychiatry ... i. During the intake assessment, the registered nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Assessment Screener Version. ii. Patient reassessment will be performed once every 12 hours ... 2. Positive Screening: a. Any positive answers to the C-SSRS questions two (2) through five (5) will result in: i. Initiation of continuous 1:1 patient observation ... ii. Notification of the LIP ... iii. Completion of the safe room checklist where and when appropriate. ... 3. Notification ... a. RN notifies LIP of patient's suicidal/homicidal ideation. b. RN notifies Charge RN/Supervisory and/or Administrator on Duty that the patient expressed suicidal/homicidal ideation ... 4. Maintaining a Safe Environment ... a. Staff will establish a safe environment using the Safe Room Checklist ... c. The patient will change into a paper gown under the observation of staff ... 5. Protocol ... a. Upon positive screening, the RN will enter an order for continuous 1:1 patient observation per protocol. b. Continuous 1:1 observation orders may only be discontinued by an LIP order. ... 6. Continuous 1:1 Patient Observation ... d. The continuous 1:1 patient observer's only responsibility is to monitor the patient(s) assigned; at no time will they leave their assignment unattended. ... ."

Reference #2: Facility policy, "Patient Observation" states, " ... 3. The patient is kept within arm's reach of the caregiver at all times including bathroom, off unit procedures, and during family/significant other visits while on 1:1 or 1:2 observation. ... a. The patient will not be left unattended when on 1:1 or 1:2. Direct relief must be provided for the caregiver before the caregiver leaves the patient. ... 9. Upon initiation of 1:1 or 1:2 Observation for suicide and homicide risks, the following occur: a. The assigned RN informs the patient regarding the need for and the frequency of the search for dangerous items. b. The patient is placed into a paper gown. ... d. The patient is searched for potentially dangerous harmful objects ... e. The search results are documented in the medical record. f. The assigned RN oversees this process. ... ."

Reference #3: Facility document, 2018 & 2019 Behavioral Health Risk Assessment - Emergency Department states, "... Areas include... Main ED Bathroom C377... Comments/Findings: Bathroom Doors is a risk of anchor points... Action Plan to be implemented: Patients are being one on one by staff members at all time. ... Medical unit bathroom risk is mitigated by staff observation. ... ."

1. During a tour of the Emergency Department (ED) on 7/16/20, the following was revealed:

a. Upon interview, Staff #5 and Staff #12 indicated that ligature and safety risks present in the ED for patients at risk for self-harm are mitigated by placing patients on one-to-one (1:1) observation. Staff #5 confirmed that staff performing 1:1 observation must remain within an arm's length distance from the patient at all times.

b. Staff #12 identified two (2) bathrooms in the ED that may be used for suicidal patients on 1:1 observation. The first bathroom, #C374, contained a safety sink and safety toilet, however, grab bars, which present a ligature risk, were present. The second bathroom, #C377, was not mitigated for suicidal patients and contained a sink, toilet, grab bars, and mirror, which present ligature and safety risks.

(i) Upon interview at 11:00 AM, Staff #13 who was performing a 1:1 observation, stated, "When I have psychiatric patients who need to go to the bathroom, I take them, but I leave the door cracked so I can see them. I stay outside the bathroom." When asked if Staff #13 follows the same process if the patient is suicidal, he/she stated, "Yes. But I make sure they don't lock the door so I can get in there."

(ii) Upon interview at 11:35 AM, Staff #17, who was currently performing a 1:1 observation stated, "If I'm doing a 1:1 on a suicidal patient and they have to go to the bathroom, I take them and stand outside the door. I don't let it close. I leave it cracked to give them space." Staff #17 confirmed that he/she would take the patient to bathroom #C377 "because it's closer." Bathroom #C377 had no mitigating safety features for patients at risk of self-harm. The facility's policy for suicidal patients indicates that staff must stay within arm's length of the patient at all times, including in bathrooms. The facility's 2019 Behavioral Health Risk Assessment for the ED states, "Medical Unit bathroom risk is mitigated by staff observation."

2. On 7/16/20, Staff #1 and Staff #3 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 4:50 PM. An acceptable IJ removal plan was received from the facility on 7/17/20 at 2:00 PM.

On 8/19/20, an onsite visit was conducted to assess facility compliance with the IJ removal plan. During the onsite visit, the following was conducted: a tour of the ED, Crisis ED, and Inpatient Psychiatric Unit, review of staff education, staff interviews, and medical record review, to determine facility compliance with the Patient Observation Policy. At 10:09 AM, during a tour of the Inpatient Psychiatric Unit Big Conference Room, the previous three (3) wall mounted "office phones" containing coiled, plastic cords were removed and no longer hanging on the wall. At 10:13 AM, in the Crisis ED, the "office phones" with cords that were previously at the nurses station were replaced with cordless telephones. At 10:49 AM, Staff #41, the Director of Education, confirmed that the re-education to the ED staff on the facility's one-to-one policy began on 7/16/20 and continued until all of the ED staff were re-educated. Staff #41 provided documentation of 100% compliance with the re-education. At 10:20 AM, interviews were conducted with Staff #35, Staff #36, Staff #37 and Staff #38. All four (4) staff confirmed they were re-educated on the facility's one-to-one policy, and were able to correctly articulate the policy. During medical record review of patients on 1:1 or 1:2 observation, after the IJ removal plan completion date of 8/16/20, it was determined that three (3) of four (4) Medical Records (#18, #19, #20) lacked the required Patient Observation Record, as indicated in facility policy. In Medical Record #23, the Patient Observation Record was not initiated on time. It was determined the facility was not in compliance with its IJ removal plan. The IJ was not removed.

On 9/14/20, a second onsite visit was conducted to assess the facility's compliance with the required medical record documentation identified in the IJ removal plan. During the onsite visit, staff interviews were conducted and ten (10) medical records were reviewed to determine compliance with one-to-one (1:1) and one-to-two (1:2) observation. The facility was in compliance with its IJ removal plan and the IJ was removed.

3. Review of Medical Record #1 on 7/16/20 revealed the following:

a. The patient arrived to the ED on 7/14/20 at 11:55 AM with a chief complaint of depression and suicidal ideation. The patient was triaged at 11:58 AM and assigned an acuity level of three (3).

(i) ED triage note dated 7/14/20 at 12:16 PM states, "Nursing office called for one to one told none available."

(ii) ED note dated 7/14/20 at 12:55 PM states, "Pt (patient) not in intake area. Intake nurse [name of nurse] looking for patient at this time."

(iii) ED note dated 7/14/20 at 1:31 PM states, "A search was conducted of all the ED rooms, bathrooms, and waiting rooms. Patient not found. Notified [name of police department] Police, physician, and ED Director [name of Director]. Cannot notify family due to not having a phone number."

b. There was no evidence in the medical record that the patient received a C-SSRS Suicide Risk Assessment at triage, as indicated in facility policy.

c. There was no evidence in the medical record that the patient was placed on 1:1 observation, as indicated in facility policy.

d. There was no evidence in the medical record that the RN notified a Charge RN, Supervisor, or Administrator on Duty, that the patient expressed suicidal/homicidal ideation, as indicated in facility policy.

e. There was no evidence in the medical record that the patient was searched for potentially dangerous or harmful objects and placed in a paper gown, as indicated in facility policy.

f. Upon interview on 7/16/20 at 11:50 AM, Staff #5 and Staff #11 confirmed that the facility did not implement its policy and procedure for the care of suicidal patients. Staff #5 stated, "The patient was triaged while sitting in a chair at the nurse's station. He/she was not placed in a bay. We know that the patient was not placed in a paper gown. The nurse tried to get a 1:1 because he/she called the staffing office, but when one was not available he/she should not have left the patient alone. When you look at the staffing sheets for that day, we had techs on the floor that could have been pulled to do the 1:1. There was an opportunity for techs to be moved. We are still trying to figure out what happened."

4. On 7/16/20, Staff #1 and Staff #3 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 4:50 PM.

An acceptable IJ removal plan was received from the facility on 7/17/20 at 2:00 PM.

On 8/19/20, an onsite visit was conducted to assess facility compliance with the IJ removal plan. During the onsite visit, the following was conducted: a tour of the ED, Crisis ED, and Inpatient Psychiatric Unit, review of staff education, staff interviews, and medical record review, to determine facility compliance with the Patient Observation Policy. At 10:09 AM, during a tour of the Inpatient Psychiatric Unit Big Conference Room, the previous three (3) wall mounted "office phones" containing coiled, plastic cords were removed and no longer hanging on the wall. At 10:13 AM, in the Crisis ED, the "office phones" with cords that were previously at the nurses station were replaced with cordless telephones. At 10:49 AM, Staff #41, the Director of Education, confirmed that the re-education to the ED staff on the facility's one-to-one policy began on 7/16/20 and continued until all of the ED staff were re-educated. Staff #41 provided documentation of 100% compliance with the re-education. At 10:20 AM, interviews were conducted with Staff #35, Staff #36, Staff #37 and Staff #38. All four (4) staff confirmed they were re-educated on the facility's one-to-one policy, and were able to correctly articulate the policy. During medical record review of patients on 1:1 or 1:2 observation, after the IJ removal plan completion date of 8/16/20, it was determined that three (3) of four (4) Medical Records (#18, #19, #20) lacked the required Patient Observation Record, as indicated in facility policy. In Medical Record #23, the Patient Observation Record was not initiated on time. It was determined the facility was not in compliance with its IJ removal plan. The IJ was not removed.

On 9/14/20, a second onsite visit was conducted to assess the facility's compliance with the required medical record documentation identified in the IJ removal plan. During the onsite visit, staff interviews were conducted and ten (10) medical records were reviewed to determine compliance with one-to-one (1:1) and one-to-two (1:2) observation. The facility was in compliance with its IJ removal plan and the IJ was removed.

5. Review of Medical Record #8 on 7/17/20 revealed the following:

a. The patient arrived to the ED on 7/14/20 at 11:22 PM with a chief complaint of suicidal ideation. The patient was found standing on a bridge attempting to jump and was brought into the ED by police. The patient received a C-SSRS Suicide Risk Assessment upon triage at 11:30 PM. The patient was admitted to the ED Crisis Unit and subsequently transferred to the IPU on 7/16/20 at 12:52 PM.

b. The patient's nursing admission assessment for the IPU was completed at 3:00 AM. There was no evidence that a C-SSRS Suicide Risk Assessment was completed during the intake assessment, as indicated in facility policy.

c. There was no evidence that a C-SSRS Suicide Risk Assessment was performed once every twelve (12) hours, as indicated in facility policy.

6. Review of Medical Record #9 on 7/17/20 revealed the following:

a. The patient arrived to the ED on 7/14/20 at 6:51 AM with a chief complaint of suicidal ideation. The patient received a C-SSRS Suicide Risk Assessment upon triage on 7/14/20 at 7:07 AM and was subsequently transferred to the IPU on 7/15/20 at 11:41 PM. The patient received a C-SSRS Suicide Risk Assessment at 7/16/20 at 12:00 AM during the intake assessment.

b. There was no evidence that a C-SSRS Suicide Risk Assessment was performed once every twelve (12) hours, as indicated by facility policy.

7. Review of Medical Record #11 on 8/28/20 revealed the following:

a. The patient arrived to the ED on 8/26/20 at 2:36 AM with a chief complaint of behavioral problems. The patient was triaged at 2:36 AM and assigned an acuity level of three (3). The patient received an MSE at 2:48 AM.

b. ED Provider notes dated 8/26/20 at 3:23 AM state, "The pt (patient) is a 17 year old male with no prior psychiatric [sic] who presented to the pediatric ER accompanied by EMS and the mother with a complaint of bizarre behavior while in the home of his aunt. ... He admits to breaking a bowl and stating that he would kill himself. ... The pt states that he has no active plan to harm himself or others. ... Presenting symptoms: aggressive behavior and bizarre behavior... ."

c. There was no evidence in the medical record that the patient received a C-SSRS Suicide Risk Assessment or a Homicide Risk Assessment upon triage, as indicated by facility policy.

8. Staff #1, Staff #3, Staff #4, Staff #26, and Staff #29 confirmed the above findings.

B. Based on observation, staff interviews, and review of facility policy and facility documents, it was determined that the facility failed to ensure that patients at risk of self-harm are cared for in a safe environment.

Findings include:

Reference #1: Facility policy, "Suicidal Patient Risk Assessment" states, "2. Patients identified at risk for suicide or homicide will be protected by having their immediate safety needs met by the most appropriate action(s) based on the setting. ... 4. Maintaining a Safe Environment... a. Staff will establish a safe environment using the Safe Room Checklist. b. All objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care should be removed immediately. ... ."

Reference #2: Facility document, "Safe Room Checklist" states, "... Remove the following from the patient rooming area unless medically indicated... telephone... ."

Reference #3: Facility document, "2018 and 2019 Behavioral Health Risk Assessment - Emergency Department" states, "Rationale/Assessment Methods... If cords are present, they should be 12 inches or less. Cords of any length are not recommended for seclusion rooms. ... Comments/Findings: Cords medically necessary for care, all other risks removed when room safety checklist is completed. ... Action Plan to be implemented: Risk mitigated with checklist and training... Date Complete: Completed Feb 2019."

Reference #4: Facility document, 2018 and 2019 Behavioral Health Risk Assessment - G Yellow Psychiatric Unit" states, "... Rationale/Assessment Methods: Cords should be too short to use to wrap around a neck and hang from any securing point (maximum 12 inches). Wall telephones should only be in locations that can be continuously observed by staff and the cord between the telephone base and the hand set should be as short as practically possible. ... ."

1. During a tour of the ED-Crisis Unit on 7/16/20, Staff #14 indicated that patients are allowed to make phone calls with a phone located at a desk near the nurse's station. The telephone observed, which is used by patients, was an "office phone" with a coiled, plastic cord. The coiled plastic cord could stretch well beyond the maximum cord length of twelve (12) inches.

a. Upon interview, Staff #15 stated that the phone did not represent a ligature risk because "there was always someone with patients when they make phone calls."

2. During a tour of the Inpatient Psychiatric Unit on 7/16/20, three (3) wall mounted "office phones" containing coiled, plastic cords were observed in the Big Conference Room. The coiled plastic cords could stretch well beyond the maximum cord length of twelve (12) inches. The Big Conference Room was locked with no patients present.

a. Upon interview, Staff #24 indicated that staff bring patients into the Big Conference Room "one by one" to make phone calls. When asked if he/she thought the wall mounted phones presented a ligature risk to suicidal patients, Staff #24 stated that he/she did not because the patients are "never alone and always supervised when using the phones."

b. Upon interview, Staff #24 confirmed that large group activities are held in the Big Conference Room, where the staff to patient ratio can be two (2) staff members to eighteen (18) patients. Upon interview, Staff #24 confirmed that the three (3) wall mounted "office phones" remain in the conference room and are accessible to patients during the large group activities.

3. On 7/16/20, Staff #1 and Staff #3 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 4:50 PM. An acceptable IJ removal plan was received from the facility on 7/17/20 at 2:00 PM.

On 8/19/20, an onsite visit was conducted to assess facility compliance with the IJ removal plan. During the onsite visit, the following was conducted: a tour of the ED, Crisis ED, and Inpatient Psychiatric Unit, review of staff education, staff interviews, and medical record review, to determine facility compliance with the Patient Observation Policy. At 10:09 AM, during a tour of the Inpatient Psychiatric Unit Big Conference Room, the previous three (3) wall mounted "office phones" containing coiled, plastic cords were removed and no longer hanging on the wall. At 10:13 AM, in the Crisis ED, the "office phones" with cords that were previously at the nurses station were replaced with cordless telephones. At 10:49 AM, Staff #41, the Director of Education, confirmed that the re-education to the ED staff on the facility's one-to-one policy began on 7/16/20 and continued until all of the ED staff were re-educated. Staff #41 provided documentation of 100% compliance with the re-education. At 10:20 AM, interviews were conducted with Staff #35, Staff #36, Staff #37 and Staff #38. All four (4) staff confirmed they were re-educated on the facility's one-to-one policy, and were able to correctly articulate the policy. During medical record review of patients on 1:1 or 1:2 observation, after the IJ removal plan completion date of 8/16/20, it was determined that three (3) of four (4) Medical Records (#18, #19, #20) lacked the required Patient Observation Record, as indicated in facility policy. In Medical Record #23, the Patient Observation Record was not initiated on time. It was determined the facility was not in compliance with its IJ removal plan. The IJ was not removed.

On 9/14/20, a second onsite visit was conducted to assess the facility's compliance with the required medical record documentation identified in the IJ removal plan. During the onsite visit, staff interviews were conducted and ten (10) medical records were reviewed to determine compliance with one-to-one (1:1) and one-to-two (1:2) observation. The facility was in compliance with its IJ removal plan and the IJ was removed.

4. Staff #1, Staff #3, Staff #4, Staff #26, and Staff #29 confirmed the above findings.


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C. Based on staff interview, review of ten (10) of ten (10) Medical Records (#14, #15, #16, #17, #18, #19, #20, #21, #22 and #23), and review of facility policies and procedures, on 8/19/20, it was determined that the facility failed to implement and adhere to safety measures during 1:1 monitoring, with continuous visual observation, to ensure patient safety and wellbeing.

Findings include:

Reference: Facility policy titled "Patient Observation" States, " ...Date Reviewed/Revised: ...7/2020 ...III. Definitions ...Constant Observation (CO): Observer is within constant visual sight of the patient(s). Continuous 1:1 Observation: 1:1 monitoring with continuous visual observation. ...V. Policy/Procedure ...4. General Patient Observation Expectations ... 5. Constant Patient observation (1:2 or group) a. The patient is kept within eye sight [sic] patient observer at all times including bathroom, ...b. The Patient Record for Constant Observation will be completed by the patient observer, and signed by the RN at the end of the required time period. c. The Patient Record for Constant Observation is placed in the patient's medical record under the Nursing Documentation section. 6. Continuous 1:1 Patient Observation a. The patient is kept within arm's reach of the caregiver at all times including bathroom, ... b. The Patient Observation Record for 1:1 Suicide/Homicide Precautions will be completed by the observer, signed by the RN at the end of the required time period. c. The Patient Observation Record for 1:1 Suicide/Homicide Precautions is placed in the patient's medical record under the Nursing Documentation section. ...8. Documentation a. Every patient on observation, and [sic] will have documentation on the appropriate Patient Observation Record ...e. Completed records are to be placed in the patient's medical record. ..." On 9/2/20, Staff #1 confirmed that the Patient Observation Policy that was provided and dated 7/2020 was reviewed without changes and is the same as the 3/1/2020 Patient Observation Policy.

1. On 8/19/20, five (5) of eight (8) Medical Records (#14, #16, #17, #18, and #20) reviewed, of patients with continuous 1:1 Patient Observation orders, failed to contain a Patient Observation Record in accordance with the facility policy referenced above.

a. Medical Records #14, #16, #17, #18, and #20, were reviewed in the presence of Staff #2 and Staff #5 and revealed the following:

(i) In Medical Record #14, on 7/15/20 at 02:50 AM, there was a STAT order for continuous 1:1 patient observation for suicidal ideations.

(ii) In Medical Record #16, on 7/12/20 at 8:00 AM, there was a STAT order for continuous 1:1 patient observation for behavioral problems.

(iii) In Medical Record #17, on 7/13/20 at 9:40 PM, there was a STAT order for continuous 1:1 patient observation for behavioral problems.

(iv) In Medical Record #18, on 8/17/20 at 7:10 PM, there was a STAT order for continuous 1:1 patient observation for agitation.

(v) In Medical Record #20, on 8/18/20 at 10:20 PM, there was a STAT order for continuous 1:1 patient observation for elopement.

b. The Patient Observation Records for Medical Records #14, #16, #17, #18, and #20 were requested by this surveyor and not received.

(i) At 2:30 PM, Staff #2 confirmed that the Patient Observation Records were unable to be located and could not be provided at the time of the survey.

(ii) Without Patient Observation Records it could not be determined if continuous 1:1 patient observation, was implemented and maintained, in accordance with the facility policy referenced above.

c. The above findings were confirmed by Staff #2 and Staff #5 at the time of the findings.

2. On 8/19/20, two (2) of two (2) Medical Records (#15 and #19) reviewed, of patients with continuous 1:2 Patient Observation orders, failed to contain a Patient Observation Record in accordance with the facility policy referenced above.

a. Medical Records #15 and #19, were reviewed in the presence of Staff #2 and Staff #5, and revealed the following:

(i) In Medical Record #15, on 6/30/20 at 03:10 PM, there was a STAT order for continuous 1:2 patient observation for suicidal ideations.

(ii) In Medical Record #19, on 8/17/20 at 7:00 PM, there was a STAT order for continuous 1:2 patient observation for elopement.

b. The Patient Observation Records for Medical Records #15 and #19 were requested by this surveyor and not received.

(i) At 2:30 PM, Staff #2 confirmed that the Patient Observation Records were unable to be located and could not be provided at the time of the survey.

(ii) Without the Patient Observation Records it could not be determined if the continuous 1:2 patient observation, was implemented and maintained, in accordance with the facility policy referenced above.

c. The above findings were confirmed by Staff #2 and Staff #5 at the time of the findings.

3. On 8/19/20, three (3) of three (3) Medical Records (#21, #22 and #23) reviewed, of patients with continuous 1:1 Patient Observation orders, lacked evidence that the 1:1 patient observation record, was implemented on time, and/or maintained in accordance with the facility policy referenced above.

a. In Medical Record #21, on 7/17/20 at 1:20 AM, there was a STAT order for continuous 1:1 patient observation for behavioral problems. The Patient Observation Record was initiated at 3:45 AM. There was no evidence on the Patient Observation Record that the continuous 1:1 observation was implemented and maintained between 1:20 AM, when the order was placed, and 3:45 AM, when the Patient Observation Record was initiated.

b. In Medical Record #22, on 7/16/20 at 1:20 PM, there was a STAT order for continuous 1:1 patient observation for suicidal ideations. Staff #2 and Staff #5 stated that the order was amended at 3:20 PM to add Sexual Preoccupation as a reason for observation, and amended again at 6:30 PM, to change the type of observation from 1:1 to 1:2, and remove Suicidal Ideations as a reason for observation. Staff #5 stated that the order for 1:2 observation was discontinued on 7/17/20 at 6:27 AM. The Patient Observation Record was initiated at 7/16/20 at 1:20 PM, and continued until 3:30 PM on 7/16/20. There was no documented evidence that the continuous 1:1/1:2 observation was maintained between 3:30 PM on 7/16/20 and 6:27 AM on 7/17/20, when the order was discontinued.

c. In Medical Record #23, on 8/17/20 at 1:20 AM, there was a Routine order for continuous patient observation for suicidal ideations. The order lacked a type of observation (1:1 or 1:2). The Patient Observation Record for 1:1 Suicide/Homicide Precautions was initiated at 7:00 AM. There was no evidence on the Patient Observation Record that the continuous patient observation was implemented and maintained between 1:20 AM, when the order was placed, and 7:00 AM when the Patient Observation Record was initiated.

d. The above findings were confirmed by Staff #2 and Staff #5 at the time of the findings.

D. Based on staff interview, review of one (1) of one (1) Medical Record (#14), review of video surveillance, and review of facility documents, it was determined that the facility failed to provide adequate supervision to ensure patient safety and well-being.

Findings include:

Reference: Facility policy titled "Patient Observation" States, " ...Date Reviewed/Revised: ...7/2020 ...III. Definitions ...Continuous 1:1 Observation: 1:1 monitoring with continuous visual observation. ...V. Policy/Procedure ...4. General Patient Observation Expectations ... 6. Continuous 1:1 Patient Observation a. The patient is kept within arm's reach of the caregiver at all times including bathroom, ..." On 9/2/20, Staff #1 confirmed that the Patient Observation Policy that was provided and dated 7/2020 was reviewed without changes and is the same as the 3/1/2020 policy.

1. On 8/19/20, Staff #5, the Executive Director of the ED, indicated that on 7/15/20, a patient (#14), in Bed #4, was on 1:1 observation. Patient #14 was escorted, by the patient observer (Staff #40), to the bathroom in the main ED hallway. When Patient #14 arrived at the bathroom, the EVS staff member (Staff #39) was cleaning the bathroom and Patient #14 punched Staff #39. Staff #5 confirmed that the incident was caught on video.

2. On 8/19/20, review of Medical Record #14 revealed the following:

a. On 7/15/20 at 02:50 AM, there was a STAT order for continuous 1:1 patient observation for suicidal ideations.

(i) The Patient Observation Record for Patient #14 was requested by this surveyor and not received. On 8/19/20 at 12:13 PM, Staff #2 confirmed that the Patient Observation Record could not be located and was unable to be provided at the time of the survey.

b. A document in Medical Record #14, dated 7/16/20, stated, " ...3. Dangerous to others or property ...a. History of Dangerous Behavior 7/15 at 10:00 : pt [patient] exchanged words w/ [with] hospital custodian seen pacing, clenching fists (w/ possible premeditation) attacked custodian leading to brain bleed ..."

c. A Progress Note in Medical Record #14, dated 7/15/20 at 19:00, stated "While in the Emergency Department, patient assaulted a member of [hospital name] housekeeping staff. According to the verbal reports by the psychiatry resident, [physician name], patient was observed wanting to use the bathroom in the Emergency Department where the housekeeping staff was working. The housekeeping staff person responded to patient's knock on the bathroom door. Patient was observed via video camera pacing with his hands clenched into fists prior to entering the bathroom and punching the housekeeping staff person. ..."

3. On 8/19/20 at 12:40 PM, the video surveillance of the 7/15/20 incident was reviewed, in the presence of Staff #2 and Staff #5. Staff #40 failed to remain within arm's reach of Patient #14 at all times, including in the bathroom, in accordance with the Patient Observation Policy referenced above.

a. On 8/28/20, Staff #1 provided a detailed timeline of the incident. The timeline is as follows:

(i) At 9:58 AM, the Patient Tech [Staff #40] is at the patient room door, watching patient.

(ii) At 9:58:22 AM, the patient [Patient #14] leaves his/her room and walks down the hall to the restroom.

(iii) At 9:58:41 AM, the patient [Patient #14] leaves restroom and walks to nurses' station.

(iv) At 9:59:02 AM, the patient [Patient #14] walks back to restroom.

(v) At 9:59:05 AM, the EVS staff person [Staff #39] leaves the restroom, sees the patient [Patient #14], and motions to the patient that the restroom is open.

(vi) At 9:59:11 AM, the patient [Patient #14] walks up to the EVS staff person [Staff #39] and punches him/her, then walks to restroom.

(vii) At 9:59:12 AM, the Patient Tech calls for help. Multiple staff are on the scene.

(viii) At 9:59:40 AM, the patient [Patient #14] was removed from restroom by Crisis Team.

4. The above findings were confirmed by Staff #2 and Staff #5 during review of the video surveillance.

Based on observation, staff interviews, review of nationally recognized guidelines, and review of facility documents, it was determined that the facility failed to adhere to Centers for Disease Control and Prevention (CDC) guidance addressing infection prevention and control recommendations for COVID-19.

Findings include:

Reference #1: CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, " ... 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic ... Implement Universal Source Control Measures ... Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow. ...HCP (healthcare professionals) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. ... ."

Reference #2: Facility document, "Mandatory Use of Procedure Masks Policy" dated 4/3/20 states, "Effective immediately, all personnel working at [name of facility], including [name of facility] employees and [name of facility] staff working in the hospital, must wear a standard procedure mask while in clinical areas and, when possible, in non-clinical areas. This policy will be in place for as long as we have a supply of these masks, which could change daily. ..."

1. Upon arrival to the Main Entrance lobby of the facility, on 7/16/20 at 10:10 AM, the following was revealed:

a. In the Main Entrance waiting area, patients/visitors who did not arrive together were sitting near one another while improperly wearing face masks. Patients/visitors were observed wearing face masks underneath the nose (the nose was exposed) or underneath the chin (the nose and mouth were both exposed).

b. Staff members present around the Main Entrance waiting area did not educate or reinforce proper mask usage for patients/visitors.

c. More than three (3) staff members walked past the Main Entrance waiting area, wearing commercial masks, that were not surgical masks.

2. During a tour of the Main ED on 7/16/20 at 10:40 AM, the following was observed:

a. Staff #7 was observed with his/her face mask around his/her chin, exposing his/her nose and mouth.

b. Staff #8 and Staff #9 were sitting next to one another in a small registration room. Both staff members were observed with their face masks around their chin, exposing their noses and mouths.

(i) Staff #8 was wearing a commercial face mask that was not a surgical mask.

3. During a tour of the Fast Track area of the ED on 7/16/20 at 11:41 AM, the following was observed:

a. Two (2) patients entered the Fast Track area without face coverings and were seated in the waiting area. Staff #11, or other staff members present, did not ask the patients to don face coverings, until prompted by this surveyor.

4. During a tour of the Medical Intensive Care Unit (MICU) on 7/16/20 at 12:05 PM, Staff #20 was observed walking down the hall towards the MICU without a mask on. Upon interview, Staff #20 stated that he/she has a mask in his/her pocket and took it off for a minute because he/she "got hot." Staff #20 then placed his/her mask on and entered the MICU.

5. Upon interview on 7/17/20, Staff #27 stated that it is the facility's policy that all staff wear surgical masks when working in the facility. Staff #27 stated that the facility has a Universal Masking Policy and stated, "We recently had a 'Just in Time' training about this before people received their masks. We talk about it in safety huddles."

6. Staff #1, Staff #3, Staff #4, Staff #5, Staff #27, and Staff #29 confirmed the above findings.

Reference #3: CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, " ... 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic ... Encourage Physical Distancing ... Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include ... Arranging seating in waiting rooms so patients can sit at least 6 feet apart. ... ."

1. Upon arrival to the facility's Main Entrance lobby on 7/16/20 at 9:45 AM, the following was observed:

a. In the Main Entrance waiting area, chairs were located immediately adjacent to each other. Seating in the waiting area was not arranged in a way that encouraged social distancing.

b. Social distancing signs were present in the waiting area; however, patients/visitors did not adhere to them. Patients/visitors that did not arrive together were observed in the waiting area sitting near one another.

c. More than five (5) staff members were present, however, no one reinforced social distancing requirements.

2. During a tour of the Fast Track area of the ED, on 7/16/20 at 11:41 AM, chairs were located immediately adjacent to each other and not arranged in a way that encouraged social distancing.

a. Social distancing signs were present; however, patients/visitors did not adhere to them. Patients/visitors that did not arrive together, were observed in the waiting area, sitting near one another.

b. More than three (3) staff members were present, however, no one reinforced social distancing requirements.

3. During a tour of the Main ED waiting area on 7/16/20 at 11:50 AM, chairs were observed immediately adjacent to each other, not arranged in a way that encouraged social distancing.

a. Upon interview, Staff #19, confirmed that if a surge of patients came into the ED at the same time, they would be required to sit in the waiting area without being screened, until the triage nurse was available to screen them. The close proximity of patient seating in the waiting area increases the risk of community-based transmission of COVID-19.

4. Staff #1, Staff #3, Staff #4, Staff #5, Staff #11, Staff #27, and Staff #29 confirmed the above findings.