HospitalInspections.org

Based on observations, interviews, review of medical record documentation for 5 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, 6 and 12), review of incident documentation for 12 of 13 patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and 13), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to the findings cited at Tag A-263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement.

Based on observations, interviews, review of medical record documentation for 5 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, 6 and 12), review of incident documentation for 12 of 13 patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and 13), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted, and failed to ensure patients were provided care in a safe setting.
* Patients at risk for suicide and other self harm behaviors were not appropriately monitored and supervised and prevented from accessing unsafe items and inflicting actual self harm: While under "1:1 observation," a patient at very high risk for suicide was allowed access to a monitor cord or cable, wrapped it around their neck, used it to "hang" themself for an unknown period of time, and was found unresponsive. While under "1:1 observation," a patient who was at known risk for repeated self harm behaviors was given a marker by hospital staff and allowed to use it to inflict self harm.
* The hospital failed to ensure safe care of a patient with paranoia and anxiety who was on an emergency mental health hold. The patient, who was assigned a "sitter," repeatedly eloped from the hospital and experienced facial and other injuries.
* The hospital failed to ensure safe care of an elderly, confused patient with impaired gait, weakness, and high fall risk. Staff failed to implement a bed alarm intervention in accordance with P&Ps, and the patient left the ED without supervision in early morning hours, and subsequently fell and was found outside the department.
* The hospital failed to ensure the safe care of a critical patient with very low body temperature. Staff applied unapproved, homemade hot packs to the patient's body and the patient experienced burns or other skin alterations.
* The hospital failed to conduct clear, thorough and timely investigations and follow up actions of incidents including those with potential and actual harm to ensure similar events did not occur. Patient incidents included attempted suicide and other self harm behaviors, falls, elopements with injuries, RT services and equipment, use of unapproved homemade hot packs, management and transfer of postpartum patients, agitated/aggressive patient behaviors, and repeated bronchoscope malfunctions including at least one malfunction during an emergency situation.
* The environment contained hazards such as unsafe items and ligature risks that had not been identified and/or mitigated and created risk for and actual self harm.
* Environmental risk assessment and mitigation processes and documentation were incomplete and unclear.
* Environmental risk assessment and mitigation P&Ps and staff training materials were not developed and implemented.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient's Rights: Care in a Safe Setting. Those findings reflect the hospital's failure to ensure the patient's right to receive care in a safe setting; and failed to ensure patients were appropriately monitored, supervised, and provided care in a safe environment that prevented access to unsafe items that created risk for and actual self harm; and other unsafe events.

2. Refer to the findings cited at Tag A145, CFR 482.13(c)(3) - Standard: Patient's Rights: Free from Abuse/Harassment. Those findings reflect the hospital's failure to ensure investigations and follow up actions to potential abuse and neglect events were timely, clear, and complete to prevent recurrence.

Based on observations, interviews, review of medical record documentation for 5 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, 6 and 12), review of incident documentation for 12 of 13 patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and 13), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted, and failed to ensure patients were provided care in a safe setting.
* Patients at risk for suicide and other self harm behaviors were not appropriately monitored and supervised and prevented from accessing unsafe items and inflicting actual self harm: While under "1:1 observation," a patient at very high risk for suicide was allowed access to a monitor cord or cable, wrapped it around their neck, used it to "hang" themself for an unknown period of time, and was found unresponsive. While under "1:1 observation," a patient who was at known risk for repeated self harm behaviors was given a marker by hospital staff and allowed to use it to inflict self harm.
* The hospital failed to ensure safe care of a patient with paranoia and anxiety who was on an emergency mental health hold. The patient, who was assigned a "sitter," repeatedly eloped from the hospital and experienced facial and other injuries.
* The hospital failed to ensure safe care of an elderly, confused patient with impaired gait, weakness, and high fall risk. Staff failed to implement a bed alarm intervention in accordance with P&Ps, and the patient left the ED without supervision in early morning hours, and subsequently fell and was found outside the department.
* The hospital failed to ensure the safe care of a critical patient with very low body temperature. Staff applied unapproved, homemade hot packs to the patient's body and the patient experienced burns or other skin alterations.
* The hospital failed to conduct clear, thorough and timely investigations and follow up actions of incidents including those with potential and actual harm to ensure similar events did not occur. Patient incidents included attempted suicide and other self harm behaviors, falls, elopements with injuries, RT services and equipment, use of unapproved homemade hot packs, management and transfer of postpartum patients, agitated/aggressive patient behaviors, and repeated bronchoscope malfunctions including at least one malfunction during an emergency situation.
* The environment contained hazards such as unsafe items and ligature risks that had not been identified and/or mitigated and created risk for and actual self harm.
* Environmental risk assessment and mitigation processes and documentation were incomplete and unclear.
* Environmental risk assessment and mitigation P&Ps and staff training materials were not developed and implemented.

Findings include:

1.a. The P&P titled "Patient Safety Event Reporting System - Policy," dated "Most Recent Review" 02/22/2022 reflected:
* "This policy exists to provide guidance to St. Charles Caregivers and Providers on the intended use of the Safety Alert System, including what, when and how to report near miss and suspected patient safety events. All Caregivers and Providers are encouraged to use the Safety Alert system for blame-free internal reporting of a system or process failure."
* "Safety Alert System: The approved electronic system for reporting, communication, analysis, response and documentation of information about actual and near miss patient safety events occurring in the course of clinical care."
* "Reporting: The Safety Alert System reports will include the date, time, location, category of event, harm level and a brief description of the event ... The types of patient safety events to be reported include but are not limited to ... Any occurrence that is inconsistent with the routine care and that results in actual or near-miss harm of a patient. Occurrences may include: patient falls, surgical or procedural complications, burns, skin integrity issues (e.g., pressure injuries, tears), delays in care and treatment, or medication errors. These will also include unanticipated, patient safety events causing death, permanent harm, or sever (sic) temporary harm, also known as Sentinel Events ... Any occurrence involving clinical practice that is inconsistent with written organizational policies, procedures and standards of care. These will include incidents where the deviation poses actual or potential harm to patients ... Behaviors that may jeopardize patient safety and are in conflict with SHCS (sic) expectations for professionalism and standards of conduct ... Any occurrence in which equipment or devices performed inconsistently from expected operation and that results in actual or near miss harm to a patient or Caregiver. This also applies to the physical plant, where hazards may be recognized and should be reported for remediation."
* "It is expected that direct communication and/or escalation through appropriate channels will be utilized for optimal and timely address of situations involving patient safety."
* "Analysis: A standard method for the analysis of patient safety events reported through the Safety Alert System will be used. The Risk Management and Patient Safety department is responsible for the identification of risks, investigation, communication with those involved and/or supervisors, managers or other leaders, and other methods for evaluation and analysis to understand causes and contributory factors."
* "Response: Several actions may be taken in response to safety alerts, including but not limited to ... No further action other than tracking ... Initiation of further investigation for fact-finding purposes ... Analysis methods to understand root causes, failures modes and contributory factors ... Root Cause Analysis ... Failure Modes Effects and Analysis ... and/or other evaluative tools."
* "In collaboration with system leadership, communication and mitigating steps to prevent future patient harm."
* "Documentation will include ... information learned through the investigation."

1.b. The P&P titled "Columbia-Suicide Severity Rating Scale Screening (C-SSRS) - NPSG 15," dated effective 12/19/2017 reflected:
* "Definitions ... Patient Safety Checklist - Check list for safety precautions ... and environmental changes to decrease risk of environment."
* "Instructions" reflected "During completion of the admission data and history ... the nurse will utilize the Columbia-Suicide Severity Rating Scale screening tool (C-SSRS) to determine the patient's risk of suicide for all patients over the age of 12. The results of the C-SSRS screening will assist the nurse in identifying the patient's level of risk for suicide, changes in environmental features that may assist in decreasing the risk for suicide and addressing the need for further assessment, intervention, and referral."
* "All patients are asked Questions #1 & #2 ... 1) Wish to be dead: In the past month have you wished you were dead or asleep and could not wake? ... 2) Suicidal Thoughts: Have you had any actual thoughts of killing yourself in the last month? ... If the patient responds with YES to question 2, the nurse will ask the patient questions 3 through 6. If the patient responds with "NO to question 2, the nurse will skip to question 6. 3) Suicidal Thought with Method (without Specific Plan or Intent to Act): Have you been thinking about how you might kill yourself? ... 4) Suicidal Intent (without Specific Plan): Have you had these thoughts and had some intention of acting on them? ... 5) Suicide Intent with Specific Plan: Started to work out details of how to kill self & intend to act on it? ... 6) Suicide Behavior Question: Have you ever done, started to do, or prepared to do anything to end your life?"
* "Response - Last Question Marked YES is 1 or 2 This response requires referrals at discharge ... Response - Last Question Marked YES is 3 This response requires that the nurse complete a Patient Safety Checklist, patient has 1:1 observation ... Response - Last Question Marked Yes is 4 or 5 This response requires immediate notification to the provider. The nurse completes a Patient Safety Checklist, patient has a 1:1 observation ... Response - Last Question Marked YES is 6 ... the nurse completes a Patient Safety Checklist, patient has a 1:1 observation ..."
* "Safety Checklist ... All potentially dangerous items are removed from room and/or made inaccessible to patient ... Remove all potentially dangerous items from room that will not be in use ... any unnecessary monitoring equipment/cords, tables, chairs ... Do not bring potentially dangerous items into room or remove after use Ex: ... pens or other writing utensils."

1.c. The P&P titled "Psychiatric 1-1 Sitter," dated effective 01/16/2019 reflected "At times it is necessary for a patient with a co-morbid health condition to have a 1:1 sitter while being treated medically on an acute medical unit or in the rehab unit. In order to ensure safety for both the patient and the caregiver, the caregiver is provided with additional information as well as additional training in the form of an E-learning lesson ... The "ED: Emergency Department" instructions included "Psychiatric patient sitters provide 1:1 care. As a sitter they will maintain visual monitoring of the assigned patient to ensure their safety ... "

1.d. The P&P titled "Environment of Care," dated effective 03/22/2017 reflected "The Safety Officer is appointed by the Chief Executive Officer of SCHS and is responsible for identifying and reducing safety hazards throughout SCHS. This individual coordinates data gathering, analysis, risk identification, mitigation and response processes to reduce safety hazards for patients, visitors and caregivers ... The Safety Officer is the primary representative for ... regulatory agency inspections related to Safety/EOC programs, and is responsible for oversight of the Safety Committees and injury Prevention Program."

1.e. The P&P titled "Patients' Rights and Responsibilities," dated effective 07/08/2014 reflected "The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned and to be free from 'all forms of abuse and harassment.' The patient may be placed in protective privacy when considered necessary for personal safety."

2. Review of the medical record and incident and investigation documentation for Patient 1 revealed they were at very high risk for suicide and the hospital failed to ensure hospital staff provided appropriate visual monitoring and maintained the patient in a safe environment in accordance with hospital P&Ps. The patient was allowed access to a cord/cable and other items, and used those to "hang" themself for an unknown period of time and was found unresponsive as follows:

2.a. The medical record of Patient 1 was reviewed with the ED NM and other hospital staff. The patient presented to SCR ED on 02/28/2020 with suicidal ideation and a hand injury.
* 02/28/2020 at 1635, Physician notes reflected the patient "presents today with an abrupt worsening of depression ... punched [their] steering wheel in a fit of anger ... states that [they were] on [their] way to ... 'jump off of something' in hopes to kill [themself] ... hold paperwork was filled out immediately so as to keep this patient safe ... was evaluated by our crisis worker who agreed with my evaluation and felt [they were] certainly unsafe to go home and was a very high risk for suicide ..."

* 02/28/2020 at 1644, RN triage notes reflected the patient's acuity was "Emergent" and at 1645, the response on a CSSRS documented by the RN was "Yes" to questions 1. through 6. as follows:
"1. Have you wished you were dead or wished you could go to sleep and not wake up?"
"2. Have you had any actual thoughts of killing yourself?"
"3. Have you been thinking about how you might do this?"
"4. Have you had these thoughts and had some intention of acting on them?"
"5. Have you started to work out or worked out the details of how to kill yourself? Do you intent (sic) to carry out this plan?"
"6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?"
In addition, at 1645, the response documented by the RN to CSSRS question "6a Was this within the past three months?" was "Less than 1 week ago."
* 02/28/2020 at 1654, ED Tech "Suicide Check" and "Safety" notes reflected:
- "Patient Location ... In Room"
- "Patient Activity ... Awake"
- "Room Check ... Yes"
- "Precautions ... Suicide"
- "Interventions ... Sitter"
- "Visual Checks ... Continuous 1:1"

* 02/28/2020 at 1705, RN notes reflected the patient was moved to ED Room 8.

* 02/28/2020 at 1739, RN notes reflected "... Patient reports SI and polysubstance abuse. [They state], 'I hate myself and want to die' ..."

* 02/28/2020 at 1744, 1745 and 1800 ED Tech "Suicide Check" notes reflected "Room Check ... Yes."

* 02/28/2020 at 1802, RN notes reflected "Pt states several times that [they] just [want] to die and [are] planning on it. Pt informed that [they are] on a mandatory hold and cannot leave."

* 02/28/2020 at 1830, RN notes reflected "Sitter at door ..."

* 02/28/2020 at 1845 and 1900 ED Tech "Suicide Check" notes reflected "Room Check ... Yes."

* 02/28/2020 at 1939, RN notes reflected "Sitter at door, SW reports that Pt was not very communicative."

* 02/28/2020 at 2020, RN notes reflected "pt agitated and pacing in room ... wanting to leave and repetitively asking for [their] belongings."

* 02/28/2020 at 2052, RN notes reflected "When [they were] informed [they were] on a hold and not allowed to leave [they] became more and more anxious. [Physician] went into pt room to inform [them] [they] will be here until the morning ... found patient hanging forward with the monitor plug in cord (that is unable to be pulled out of monitor) wrapped around pt neck and pt with full body weight on cord. [Physician] pulled pt out of cord and found pt to be unresponsive but breathing. Pt immediately put onto gurney and moved to trauma room for assessment and treatment. approx. 60-90 seconds later pt was awake and returned to baseline. This patient did have a 1:1 agency sitterwho (sic) was at doorway. It is unknown how long the patient was hanging in room on cord."

* 02/28/2020 at 2337 the patient was transferred by ambulance to SCBC ED for psychiatric evaluation and treatment.

2.b. Incident documentation for Patient 1 reflected that on 02/28/2020 the patient "brought [themself] to ER for hand pain ... placed into room 8, further into [their] visit was found to be very suicidal and [they were] placed into safety scrubs and room was cleared. Pt had made statements to staff saying that [they] wanted to die. Pt had a 1:1 agency sitter. When [they were] informed [they were] on a hold and not allowed to leave [they] became more and more anxious ... [Physician] went into room to inform [them that they] will be here until the morning ... found patient hanging forward with the monitor plug in cord (that is unable to be pulled out of monitor) wrapped around pt neck and pt with full body weight on cord. [Physician] pulled pt out of cord and found pt to be unresponsive but breathing. Pt immediately put onto gurney and moved to trauma room for assessment and treatment. approx. 60-90 seconds later pt was awake and returned to baseline ... This patient did have a 1:1 agency sitter [name] who was at doorway. it is unknown how long the patient was hanging in room on cord ..."
- "Management Investigation" notes dated 03/02/2020 at 0906 reflected "Please investigate this event and document your findings and corrective actions." A "Response Note" dated 03/05/2020 at 1340 reflected "Currently in the process of making each room safe as it relates to wires and cables, along with other equipment and supplies within the patient room. Also, enforcing the need to use Room 9 for our highest risk patients. Also assuring Room 9 is used regardless of proximity to Nurses station."
- "Cause Notes" dated 03/16/2020 at 1230 reflected "Patient placed in room 8 for proximity to nursing station. Room had been appropriately cleared with exception of cable to GE monitor ... The stool was left in the room. The patient used the stool to rest elbows on with hands by face obstructing the cable view. Lights were turned off in room, curtain pulled back but [sentence ended]"

* An investigation analysis document dated 03/12/2020 reflected:
- "A suicidal patient under continuous observation in the Redmond ED was able to covertly wrap a heart monitor cable around [their] neck and was discovered unconscious."
- "At 1641 during triage the patient stated [they were] actively suicidal and a positive CSSRS triggered a social work consult and assignment of continuous observation ... room 8 was cleared for safety. An evaluation was completed by 1917 ... and a 48 hour hold was placed ... a request was made for a transfer to the PES unit in Bend for further evaluation and treatment ... At 2010, the transfer process was initiated with a 20 minute call ... During this time the patient, who had become increasingly agitated and intimidating staff, now had settled down, crouching in the corner, elbows on a stool, appearing to be in a meditation state."
- "At 2043 the care attendant saw the patient move to a different position in the room. The caregiver providing continuous observation stood up and went to the doorway to ask the patient if [they] needed anything and got no response, assuming the patient had finally settled down and was either meditating or praying."
- "Other caregivers also laid eyes on the patient over the next few minutes as they walked by the room, noticing [their] crouched position but did not cause them alarm."
- "At 2050, the ED MD entered the room to speak to the patient and at 2051 alerted the team that they found the patient had actually wrapped the monitor cable around [their] neck and was unconscious ..."
- "Defects with using room 8 ... Room 8 is in main traffic area, continuous obs caregiver has to sit across hall from room ... Cords not managed ... Care providers in and out of room, stool left in room ... "
- "Top issues to address ... Continuous observation role standard work and expectations ... Utilization of safe room ..."
- "Continuous observation caregivers are an unskilled labor force, many contracted from an outside agency ... Inconsistent training and expectations, varying standard work, unit dependent ... Continuous observation role ... Onboarding to org - agency, half a day with St Charles ... Ongoing evaluation of sitter performance (after x shifts etc) ... varying skilled staff filling sitter role (agency, tech, CNA), expectation of shift ... "
- "Root Cause ... Inadequate constant observation performed by staff"

The documentation lacked a thorough investigation. Examples included:
* The documentation reflected "Room had been appropriately cleared with exception of cable to GE monitor" and "Cords not managed." However, the medical record reflected "found patient hanging forward with the monitor plug in cord (that is unable to be pulled out of monitor) wrapped around pt neck." The investigation was not clear regarding what was meant by the cord was "unable to be pulled out of monitor." The investigation was not clear regarding if the cord could or could not be removed from the room, and if the cord could be removed, it was not clear how or why it was not removed.
* The documentation reflected "Care providers in and out of room, stool left in room" but the investigation did not include how or why the stool was left in the room when caregivers were going in and out. There was no investigation that reflected whether any of the caregivers were interviewed to determine if they noticed the stool and cable/cord, or were aware they should be removed.
* The documentation reflected "enforcing the need to use Room 9 for our highest risk patients ... assuring Room 9 is used regardless of proximity to Nurses station." However, the investigation was not clear if Patient 1 was considered a "highest risk patient" and if using Room 8 instead of Room 9 was consistent or inconsistent with hospital P&Ps.
* The documentation reflected "... caregivers are an unskilled labor force, many contracted from an outside agency ... Inconsistent training and expectations ... varying skilled staff filling sitter role ..." However, the investigation was not clear if the sitter assigned to the patient at the time of the incident was appropriately trained in accordance with hospital P&Ps, and if not, why.
* Although the medical record reflected the room was "cleared" and staff "checked" the room multiple times before the incident occurred, the investigation did not include what staff checked, including how it was possible a stool and cable/cord were left in the room especially with consideration that multiple people were going in and out of the room before the incident occurred.
* The documentation reflected the curtain was pulled back and a "Countermeasure" was "Bundle curtain with Velcro" but the investigation was not clear what impact the curtain did or did not have on the incident.
* The documentation did not include if Room 8, including the monitor cable/cord, stool, and privacy curtain were or were not included in the hospital's environmental risk assessment.
* The investigation lacked documentation that all aspects of the incident had been critically evaluated against the hospital's P&Ps to identify deficient practices and implement corrective actions. For example, P&Ps including but not limited to those related to sitter responsibilities, sitter training requirements; patient monitoring for patients at risk for suicide; and environmental risk assessment and mitigation.

There was no investigation that reflected whether abuse and neglect, as defined by CMS, were ruled out.

There was no further investigation documentation.

2.c. During an interview with the CNO on 06/30/2022 at 1030, they confirmed there was no further investigation documentation.

2.d. During an interview on 06/30/2022 at 1600 with the EDD, ED NM and other hospital staff, they provided the following information regarding the incident involving Patient 1:
* The patient came into the ED, developed suicidal symptoms, and was placed in ED treatment Room 8 with a "sitter." The hospital had a process for clearing Room 8 to make it "safer" for patients at risk for suicide. Clearing the room included removing unsafe items including cords, stools and other items that could be used for self harm.
* Room 8 had a sliding glass door and window between the room and ED corridor, and a privacy curtain inside the room that could be pulled open or closed across the glass door and window.
* The sitter was sitting across the hall from the room "further than usual." The privacy curtain was "bunched" into the same room corner where the patient was sitting. A wall mounted monitor with an attached monitor cord was also in the same room corner. The sitter could not see the monitor cord or what the patient was doing with the cord because the cord was behind the bunched curtain and was a similar color as the wall.
* The light was off inside the room.
* The sitter could not fully see the patient's hands because the sitter was facing the patient's back, the room light was off, and there may have been a glare on the glass door and/or window.
* A physician entered the room and found the patient "on [their] knees with elbows on a stool" in the same corner as the "bunched" privacy curtain and monitor cord. The patient was leaning forward with the monitor cord around their neck.
* The monitor cord and the stool the patient used during this incident should have been removed from the room during the process of clearing the room and making the room "safer," in accordance with the hospital's P&P, but that was not done.

3. Review of the medical record and incident and investigation documentation for Patient 2 revealed that hospital staff failed to maintain the patient in a safe environment in accordance with hospital P&Ps. The patient was well known by staff for their repeated self harm behaviors. However, staff gave the patient a marker or markers and failed to provide appropriate 1:1 visual monitoring and they were allowed to use those to inflict self harm as follows:

3.a. The medical record of Patient 2 was reviewed with the ED NM and other hospital staff. The patient presented to SCR ED on 05/18/2022 at 1949 by police for "suicide attempt by cutting legs."
* 05/18/2022 at 2007, the response on a CSSRS documented by the RN was "Yes" to questions 1., 2. and 6. as follows:
"1. Have you wished you were dead or wished you could go to sleep and not
wake up?: Yes (Not currently)"
"2. Have you had any actual thoughts of killing yourself?: Yes (Not currently)"
"6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?: Yes"

* 05/18/2022 at 0952, RN notes reflected the patient was roomed in ED Room 9.

* 05/20/2022 at 0742, RN notes reflected "... pt with 1:1 sitter to ensure pts safety."

* 05/20/2022 at 1229, EMT "Safety" notes reflected:
"Precautions: Self destructive; Suicide"
"Interventions: Sitter"
"Visual Checks: Continuous 1:1"

* 05/20/2022 at 1300, MSW notes reflected "Reason for Hospitalization ... Pt is on a civil commitment. Pt has a hx dx of Borderline Personality Disorder, MDD and PTSD ... brought in due to suicide attempt via cutting [their] thighs deep enough to result in getting stitches ..."

05/20/2022 at 2230 RN "Suicide Check" and "Safety" notes reflected:
"Patient Location: In room"
"Patient Activity: Awake (pacing)"
"Room Check: Yes"
"Precautions: Self destructive; Suicide"
"Interventions ... Sitter"
"Visual Checks: Continuous 1:1"
"Self Injurious Thoughts ... 'I am so agitated because of my left arm pain that I want to punch a wall" rates agitation at a 9/10. RN Notified. Meds given ..."

* 05/20/2022 at 2240, RN notes reflected "pt stating [they are] feeling agitated and violent at this time and stating [they do] not think vistaril will help [them] at this time. [Physician] notified and ativan order placed."

* 05/20/2022 at 2245, RN "Suicide Check" and "Safety" notes reflected "Patient Location: In room"
"Patient Activity: Awake (Presented with court paperwork, reading it, gave it back to hospital staff 'I don't (sic) want to read it, it is making me more agitated')"
"Room Check: Yes"
"Precautions: Self destructive; Suicide"
"Interventions ... Sitter"
"Visual Checks: Continuous 1:1"

* 05/21/2022 at 0725, RN notes reflected "1:1 remains for pts safety."

* 05/21/2022 at 1515, EMT "Suicide Check" and "Safety" notes reflected:
"Patient Activity: Awake (pt expresses agitation (sic), 'I want to punch the wall,' verbal de-escalation successful so far. Did physical exercises (wall sits, lunges) to find 'release' like what pt experiences when [they harm themself] without success, pt requests nicotine but no patch)"
"Room Check: Yes"
"Precautions: Self destructive; Suicide"
"Interventions ... Sitter"
"Visual Checks: Continuous 1:1"

* 05/22/2022 at 0715, RN notes reflected:
"Sitter: Continued ... Sitter Type: Staff ... Indications for Sitter: Suicidal risk; Other (Comment) (Civil hold)"

* 05/22/2022 at 1130, EMT "Suicide Check" and "Safety" notes reflected:
"Patient Location: In room"
"Patient Activity: Awake"
"Room Check: Yes"
"Precautions: Self destructive; Suicide"
"Interventions ... Sitter"
"Visual Checks: Continuous 1:1"

* 05/22/2022 at 1155, RN notes reflected "As this nurse covering the sitter, noted that the pt was making a strange movement on [their] leg, entered the pts room and [the patient] pulled up the covers ... this nurse pulled back the covers and noted that the pt broke a marker in half and was using the sharp end of it to cause a superficial laceration onto the L lower extremity, pt was stopped, markers removed ..."

* 05/22/2022 at 1215, RN notes reflected:
"Patient found by staff with approx 3cm laceration to left lower medial leg. Patient reports using 'a broken marker' to cut self ... states 'I flushed it down the toilet' ... When debriefed with patient regarding incident patient states 'I just don't care anymore.'"

* 05/22/2022 at 1249, EMT notes reflected:
"Pt. was given markers to color, pt. used marker cap to create superficial laceration on lower leg ..."

3.b. Incident documentation for Patient 2 reflected that on 05/22/2022 at 1238 a "... psych patient in bed 9 Was (sic) given marker, paper to draw with social worker ... Approx (sic) 1 hour later, an RN was breaking the sitter and saw the patient making small movements under the blanket and was found to be self harming to left lower leg ... Entire room was searched ..."
* "Action Notes" dated 05/25/2022 at 1738 reflected only "Crisis patients can be unpredictable, thankfully the sitter was watching closely and corrected the situation. We need to ensure that variances are communicated between caregivers."

The next and final note was nearly a month later on 06/21/2022 at 0723 and it reflected only "Risk Closure ... Assigned to Patient Safety Risk Manager, Team Admitting ICD-9 Code: Surgical Procedure Code: Resulting Injury Code: 'E' Code describe the incident: Extra # of stay days: Management Adjustment:"

There was no further documentation of an investigation or follow up actions.

The documentation lacked a thorough investigation and follow up actions. Examples included:
* The documentation reflected "given marker, paper to draw with social worker." It was not clear who gave the patient the marker. There was no investigation regarding the type of marker given to the patient, where the marker came from, if the patient was or was not assessed and determined safe to have a marker, and if the social worker was or was not present with the patient when the incident occurred.
* The documentation reflected approximately an hour after the patient was given the marker, an RN breaking the sitter "saw the patient making small movements under the blanket and was found to be self harming." There was no investigation that reflected when the patient was last seen before the incident occurred, what they were doing, and if they had a marker or markers.
* There was no investigation regarding whether the patient's plan of care and physician orders were followed or not followed regarding supervision and monitoring.
* There was no investigation that reflected how the patient was able to get a marker or markers under the blanket and use it to inflict self harm if they were under continuous 1:1 visual checks.
* It was not clear if the patient had a marker or multiple markers. The documentation reflected the patient flushed the marker down the toilet. It was not clear how the patient was able to transport a marker to the bathroom and flush it down the toilet if they were under continuous 1:1 visual checks.
* The RN notes reflected the patient broke a marker in half and used the sharp end to self harm. The EMT notes reflected the patient used the marker cap to self harm. It was not clear what the patient used to self harm. If the patient used a broken marker to self harm, it was not clear how the patient was able to break the marker without anyone noticing.
* The documentation reflected the "sitter was watching closely." However, there was no investigation that reflected how this was determined.
* There was no investigation that reflected whether the sitter or the RN relieving the sitter were aware the patient had a marker prior to the incident.
* There was no documentation that reflected whether or not the social worker, sitter, or RN relieving the sitter were interviewed to elicit any of this information.
* The "Action" notes reflected "we need to ensure variances are communicated between caregivers." It was not documented what the "variances" were.
* The investigation lacked documentation that all aspects of the incident had been critically evaluated against the hospital's P&Ps to identify deficient practices and implement corrective actions. For example, P&Ps including but not limited to those related to giving potentially unsafe items to patients at risk for self harm, sitter training requirements, sitter responsibilities, and 1:1 continuous visual checks for patients at risk for self harm.

There was no investigation that reflected whether abuse and neglect, as defined by CMS, were ruled out.

Due to the hospital's failure to condu

Based on observations, interviews, review of medical record documentation for 5 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, 6 and 12), review of incident documentation for 12 of 13 patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and 13), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.
* Patient incidents included attempted suicide and other self harm behaviors, falls, elopements with injuries, RT services and equipment, use of unapproved homemade hot packs, management and transfer of postpartum patients, agitated/aggressive patient behaviors, and repeated bronchoscope malfunctions including at least one malfunction during an emergency situation.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. Refer to the findings identified under Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in a Safe Setting. Those findings reflect the hospital's failure to conduct clear, thorough and timely investigations and follow up actions to potential abuse or neglect incidents, to ensure similar events did not recur.

Based on observations, interviews, review of medical record documentation for 5 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, 6 and 12), review of incident documentation for 12 of 13 patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and 13), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined the hospital failed, it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

Based on observations, interviews, review of medical record documentation for 4 of 5 patients who received emergency services at SCR (Patients 1, 2, 5, and 12), review of incident documentation for 4 of 13 patients (Patients 1, 2, 5, and 12), review of P&Ps, review of environmental risk documentation, review of staff training materials, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients were provided care in a safe environment.
* Patients at risk for suicide and other self harm behaviors were not appropriately monitored and supervised and prevented from accessing unsafe items in the environment and inflicting self harm: While under "1:1 observation," a patient at very high risk for suicide was allowed access to a monitor cord or cable, wrapped it around their neck, and used it to "hang" themself for an unknown period of time and was found unresponsive. While under "1:1 observation," a patient who was at known risk for repeated self harm behaviors was given a marker by hospital staff and allowed to use it to inflict self harm.
* The hospital failed to ensure care in a safe environment of a patient with paranoia and anxiety who was on an emergency mental health hold. The patient, who was assigned a "sitter," repeatedly eloped from the hospital and experienced facial and other injuries.
* The hospital failed to ensure care in a safe environment of an elderly, confused patient with impaired gait, weakness, and high fall risk. Staff failed to implement a bed alarm intervention in accordance with P&Ps, and the patient left the ED without supervision in early morning hours, and subsequently fell and was found outside the department.
* The environment contained hazards such as unsafe items and ligature risks that had not been identified and/or mitigated and created risk for and actual self harm.
* Environmental risk assessment and mitigation processes and documentation were incomplete and unclear.
* Environmental risk assessment and mitigation P&Ps and staff training materials were not developed and implemented.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP: Patient's Rights. Those findings reflect the hospital's failure to ensure the provision of care in a safe environment.