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Based on observation, policy/procedure review, document review, and staff interviews, the hospital's administrative staff failed to implement systems to ensure a safe environment, including a ligature free environment, to minimize risks for patients with psychiatric diagnoses. The presence of ligature risks in the psychiatric unit are points available to psychiatric patients to attach items for the purpose of hanging or strangulation. The acute psychiatric unit census was 17 inpatients (9 patients had suicidal thoughts) and 195 hospital inpatients at the time of the complaint investigation. The following examples confirm this determination.

The hospital administrative staff failed to identify and remove or replace all non-breakaway hardware from all areas in the inpatient psychiatric unit including patient and hallway doors, and cabinets/closets. (Refer to A-144)

The hospital administrative staff failed to maintain a safe environment for suicidal patients by failing to minimize risk
factors available in psychiatric patient bedrooms and throughout the acute psychiatric inpatient unit. (Refer to A-144)

The psychiatric unit staff failed to accurately document a system of 15-minute monitoring where patients could not predict the order and timing of the 15-minute checks. (Refer to A-144)

The psychiatric unit staff failed to ensure that staff watched, by means of a monitored camera, unattended patients with suicidal ideation, occupying rooms with non-breakaway hardware including handles, non-tamper proof screws, non-tear resistant patient clothing as well as safety risk hazards throughout the inpatient unit. (Refer to A-144)

The emergency department staff failed to ensure that time limited violent restraints were removed every two hours according to the physician's order and in conjunction with hospital policy for an adolescent patients. (Refer to A-171)

The hospital's administrative staff failed to ensure all patients were informed of their rights to include:
- their right to have their own physician notified of their admission to the hospital (Refer to A-133)
- their right to be free from all forms of harassment (Refer to A-145)
- their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. (Refer to A-154)

The cummulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of psychiatric patients.

Based on document review and staff interview, the hospital failed to ensure patients were informed of their right to have their own physician notified promptly of their admission to the hospital. The hospital census was 195 inpatients at the start of the complaint investigation.

Failure to inform the patient of the right to have their own physician notified promptly of admission to the hospital could result in the patient's own physician not notified of their admission and the potential for lack of continuity of care.

Finding include:

1. Review of hospital policy titled "Rights and Responsibilities", dated 4/19/2017, lacked evidence of patients to be informed of the right to have their own physician notified promptly of admission to the hospital.

2. Review of hospital document titled "Know Your Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights. The document lacked evidence patients are informed of their right to have their own physician notified promptly of admission to the hospital.

3. During an interview on 6/12/2018 at 7:45 AM, Staff A, Director of Community Benefits and Patient Relations, confirmed the Patient Rights Policy and the document provided to patient regarding their rights lacked evidence of patients informed of the right to have their own physician notified promptly of admission to the hospital.

I. Based on observation, document reviews and staff interviews, the hospital's administrative staff failed to identify and remove or replace all non-breakaway hardware and faucets from all areas in the inpatient psychiatric unit including patient rooms, hallway doors, and cabinets/closets for 9 of 17 psychiatric patients identified on suicide precautions. (Patients #2, 3, 4, 5, 6, 7, 8, 9, 10)

Failure to establish and maintain a safe environment including non-breakaway hardware and faucets for psychiatric patients could potentially provide a point of attachment for a device used for patient strangulation or hanging and result in patient deaths or other life-threatening conditions.

Findings include:

1. Observations on 6/5/18 from 11:45 AM to 12:15 PM and from 1:55 PM to 2:15 PM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed the following doors on the Behavioral Health unit with three exposed metal door hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame.
- 15 of 15 patient room doors opened into the hallway with the exposed hinges on the hall side.
- 15 of 15 patient rooms had bathroom doors that opened into the patient room with the exposed hinges on the patient room side.
- 4 of 4 main hallway non-patient room doors opened into the hallway with exposed hinges on the hall side.
- 1 of 1 back hallway non-patient room doors opened into the hallway with exposed hinges on the hall side.
- 6 of 6 day room non-patient room doors opened into the day room with exposed hinges on the day room side.

Observations on 6/5/18 from 11:45 AM to 12:15 PM and from 1:55 PM to 2:15 PM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed the following:
- 3 of 3 non-break away door handle levers on non-patient room doors in the back hallway.
- 3 of 3 non-break away door handle levers on non-patient room doors in the day room area.
- 1 of 1 non-break away door knob on non-patient room door in the main hallway.
- 2 of 2 metal door closers mounted on the upper interior surface of the doors at the entrance to the day room. The doors at the entrance to the day room were in the open position and the metal door closers formed a V shape that extended approximately 8 inches into the door opening to the day room. A door closer is a mechanical device that closes a door after it is opened.
- In the day room - approximately 12 C shaped handles on wall cabinets surrounding the enclosed television. The C shaped handles created an opening approximately 1 inch from the cabinets.
- In the Relaxation Room - approximately 6 C shaped handles on wall cabinets surrounding the enclosed television. The C shaped handles created an opening approximately 1 inch from the cabinets.
- In the kitchenette area across from the nurse's station - approximately 9 C shaped handles on wall cabinets. The C shaped handles created an opening approximately 1 inch from the cabinets and 1 of 1 non-breakaway sink faucet.

Observations on 6/12/18 from 9:10 AM to 9:50 AM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed 9 of 15 patient rooms contained a free standing closet with exposed piano hinges that extended approximately 1 inch from the cabinets (Patient rooms #01, 02, 03, 04, 05, 06, 14, 18, 29).
A piano hinge is a hinge that has a thin pin joint and extends along the full length of the closet door.

The door/closet hinges, door knobs, door levers, handles, and faucet listed may be utilized as ligature points and sufficient areas for attachment of a hanging device that a patient could use to hang themselves and resulted in an unsafe physical environment.

2. Review of the hospital's "Safety Management Plan 2018", dated reviewed 12/19/2017, revealed in part, ". . . The Safety Management Plan addresses all elements required to provide a safe and healthy environment of care that is free of hazards and to collaborate with department management to provide staff training and monitoring the risk of injuries. . . ."

Review of policy titled "Rights and Responsibilities", dated reviewed 4/19/2017, revealed in part ". . . Mercy Medical Center maintains policies, procedures, and ongoing programs to ensure that the rights of each patient/resident are protected. . . Rights: All patients/residents, regardless of age, have the right to the following:. . .To safe care and the assurance of reasonable safety within the hospital. . . ."

Review of hospital document titled "Know Your Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, revealed in part, ". . .You have the right to safe care and the assurance of reasonable safety within the hospital. . . ."

3. Review of document titled "Work Plan for Behavioral Health Doors For presentation as Ops Council 6/12/18" failed to address all elements, including door closers, cabinet handles, and non-breakaway sink, required to provide a safe environment that is free of hazards to the patients on the psychiatric unit.

4. Review of Behavioral Services "Precaution Observation Protocols", dated reviewed February 2015, revealed in part, "Suicide Precautions - this is initiated when a patient is believed to be a threat to themselves or has a high risk for self harm. . . Remove obvious sharps from the patient's room. Remove all glass, razors, cords, belts, ties, or other obvious hazards from the patient's room. . . ."

5. Review of patient medical records on 6/5/18 at 4:35 PM with Behavioral Health Nurse Manager revealed Patients #2, 3, 4, 5, 6, 7, 8, 9, and 10 were admitted with suicidal ideations and placed on suicide precautions.

6. During an interview on 6/5/18 at 12:15 PM, 2:15 PM and 6/12/18 at 9:50 AM, the Behavioral Health Nurse Manager confirmed the door/closet hinges, door knobs, door levers, handles, and faucet listed may be utilized as ligature points and sufficient areas for attachment of a hanging device that a patient could use to hang themselves and a risk for self harm to patients.

During an interview on 6/7/18 at 12:20 PM, the Director of Facilities Management stated approximately two months ago it was determined the door hinges in the psychiatric unit needed to be reviewed. The Director of Facilities Management stated a work plan for behavioral health doors was prepared to be presented to the Ops Council on 6/12/18. The Director of Facilities Management stated nothing had been implemented at this time related to the doors and no time frame has been established to correct the concerns identified.

II. Based on observation, document review, and staff interviews, the hospital's administrative staff failed to identify and remove or replace all potential hazards, including non-tamperproof screws and tear resistant clothing, for patients that self harm or harm to others from all areas in the inpatient psychiatric unit including patient rooms, hallways, and day room areas for 9 of 17 psychiatric patients identified on suicide precautions. (Patients #2, 3, 4, 5, 6, 7, 8, 9, 10)

Failure to establish and maintain a safe environment for psychiatric patients could provide potential hazards including weapons for patient self harm or harm to others and result in patient deaths or other life-threatening conditions.

Findings include:

1. Observations on 6/5/18 from 11:45 AM to 12:15 PM and from 1:55 PM to 2:15 PM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed the following:
- 15 of 15 patient bathrooms with a non-breakable mirror mounted on the wall with 6 non-tamperproof screws.
- 15 of 15 patient rooms with one picture in each room mounted on the wall with 4 non-tamperproof screws.
- 17 of 17 patients wearing non-tear resistant scrubs.

Observations on 6/12/18 from 9:10 AM to 9:50 AM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed 10 of 15 patient rooms contained a shelf mounted on the wall with approximately 10 to 25 non-tamperproof screws (Patient rooms #1, 2, 3, 4, 5, 6, 7, 8, 10, 29)

2. Review of the hospital's "Safety Management Plan 2018", dated 12/19/2017, revealed in part, ". . . The Safety Management Plan addresses all elements required to provide a safe and healthy environment of care that is free of hazards and to collaborate with department management to provide staff training and monitoring the risk of injuries. "

Review of policy titled "Rights and Responsibilities", dated 4/19/2017, revealed in part ". . . Mercy Medical Center maintains policies, procedures, and ongoing programs to ensure that the rights of each patient/resident are protected. . . Rights: All patients/residents, regardless of age, have the right to the following:. . .To safe care and the assurance of reasonable safety within the hospital. . . ."

Review of hospital document titled "Know Your Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, revealed in part, ". . .You have the right to safe care and the assurance of reasonable safety within the hospital. . . ."

3. Review of document titled "Work Plan for Behavioral Health Doors For presentation as Ops Council 6/12/18" failed to address all elements. including non-tamperproof screws and tear resistant patient scrubs, required to provide a safe environment that is free of hazards to the patients on the psychiatric unit.

4. Review of Behavioral Services "Precaution Observation Protocols", dated reviewed February 2015, revealed in part, "Suicide Precautions - this is initiated when a patient is believed to be a threat to themselves or has a high risk for self harm. . . Remove obvious sharps from the patient's room. Remove all glass, razors, cords, belts, ties, or other obvious hazards from the patient's room. . . ."

5. Review of patient medical records on 6/5/18 at 4:35 PM with Behavioral Health Nurse Manager revealed Patients #2, 3, 4, 5, 6, 7, 8, 9, and 10 were admitted with suicidal ideations and placed on suicide precautions.

6. During an interview on 6/5/18 at 12:15 PM, 2:15 PM and 6/12/18 at 9:50 AM, the Behavioral Health Nurse Manager confirmed the non-tamperproof screws may be utilized as a hazard that could pose a risk for self harm to patients.

During an interview on 6/7/18 at 12:20 PM, the Director of Facilities Management stated approximately two months ago it was determined the door hinges in the psychiatric unit needed to be reviewed. The Director of Facilities Management stated a work plan for behavioral health doors was prepared to be presented to the Ops Council on 6/12/18. The Director of Facilities Management stated nothing had been implemented at this time related to the doors and no time frame has been established to correct the concerns identified.

During an interview on 6/11/18 at 1:44 PM, Compliance/Quality/Regulatory Staff D verified the patient scrubs are not tear resistant.

III. Based on observation, document review, and staff interviews, the hospital failed to ensure that staff watched, by means of a monitored camera, unattended patients with suicidal ideation, occupying rooms with non-breakaway hardware including handles, non-tamper proof screws, non-tear resistant patient clothing (scrubs) as well as safety risk hazards throughout the inpatient unit for 9 of 17 psychiatric patients identified on suicide precautions. (Patients #2, 3, 4, 5, 6, 7, 8, 9, 10)

Failure to monitor psychiatric patients with suicidal ideations could potentially provide patient time for self harm and result in patient deaths or other life-threatening conditions.

Findings include:

1. Observation on 6//5/18 at 2:16 PM to 2:53 PM, with Behavioral Health Nurse Manager and Director of Behavioral Health Services revealed three monitors at the nurses station with 9 camera views of patient rooms each on two monitors and 12 camera views on the third monitor of the main hallway, back hallway, back day room area, and day room area. During the observation, four staff entered and/or left the nurse's station and none of the staff looked at the monitor screens.

2. Review of policy titled "Monitoring, Camera", dated 9/27/2017, revealed in part, ". . .Criteria for Camera Monitoring generally include but are not limited to: ensuring patient safety, such as a patient with impaired judgement or potential for seizure activity. . . ."

The policy failed to address who was responsible to watch, by means of a monitored camera, unattended patients with suicidal ideations, on the psychiatric unit.

3. Review of patient medical records on 6/5/18 at 4:35 PM with Behavioral Health Nurse Manager revealed Patients #2, 3, 4, 5, 6, 7, 8, 9, and 10 were admitted with suicidal ideations and placed on suicide precautions.

4. During an interview on 6/5/18 at 2:53 PM, Staff C, Charge Nurse, and the Behavioral Health Nurse Manager acknowledged no one was assigned to watch the camera monitors but the charge nurse keeps an eye on the camera monitors when they are in the nurse's station. Also if the charge nurse is out on the floor and not in the nurse's station, then they try to have someone at the nurse's station.


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IV. Based on observation, document review, and staff interviews the hospital's administrative staff failed to establish and maintain a safe environment by not implementing staggered start locations and times for patient safety rounds for 9 of 17 patients, identified as on suicide precautions, on the psychiatric unit. The psychiatric unit of the hospital identified a census of 17 patients.

"Rounding" is a term used when staff make periodic special observations of patients with a psychiatric diagnosis who reside on a psychiatric unit. Staff periodically make these observations as they "round" (walk) the unit.

Failure to implement a system of 15-minute observations where patient's could not predict the order of the rooms or the exact period of time when observations would be conducted could potentially result in patient's predicting the frequency and knowing the amount of time they would have to harm themselves or attempt suicide before the next scheduled observation. This could potentially result in patient death or other life-threatening conditions.

Findings include:

1. Observation on 6/5/2018 at 3:15 PM of psychiatric unit staff performing rounding safety checks on the psychiatric unit revealed a form with the time pre-printed in 15-minute increments. Documentation showed that staff failed to document the actual times they observed patients or where they began and ended their observations.

2. Review of the form titled "Safety Checks - Behavioral Services", # 622-50006 and dated 06/09, in part, "Precautions: Monitored every 15 minutes"; three columns of pre-printed times starting at 0730 and ending with 0715. Each preprinted time is followed with a blank space to document the code of the patient's location and a blank space for the staff member completing the rounds to document their initials.

3. Review of policy and guidelines titled "Safety Rounds For Behavioral Services", reviewed February 2015, lacked instruction to vary the safety rounds route and timing within the 15 minute time frame to prevent patients ability to predict the next scheduled observation.

4. An interview on 6/5/2018 at 2:50 PM with Charge Nurse B revealed the preprinted time on the "Safety Checks" form is not the actual time the patient is observed. The "Safety Checks" form does not allow staff to enter the time the observation takes place. Charge Nurse B verbalized staff try to stay close to the time printed but they do not want to be predictable.

Based on document review and staff interview, the hospital failed to ensure patients were informed of their right to be free from all forms of harassment. The hospital census was 195 inpatients at the start of the complaint investigation.

Failure to inform the patient of their right to be free from all forms of harassment could result in potential harm to the patient.

Finding include:

1. Review of hospital policy titled "Rights and Responsibilities", dated 4/19/2017, lacked evidence of patients being informed of their right to be free from all forms of harassment.

2. Review of hospital document titled "Know Your Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights and failed to contain evidence of patients informed of the right to be free from all forms of harassment.

3. During an interview on 6/12/2018 at 7:45 AM, Staff A, Director of Community Benefits and Patient Relations, confirmed the Patient Rights Policy and the document provided to patient regarding their rights lacked evidence of patients being informed of the right to be free from all forms of harassment.

Based on document review and staff interview, the hospital failed to ensure patients were informed of their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. The hospital census was 195 inpatients at the start of the complaint investigation.

Failure to inform a patient of their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff could result in patients placed in unneeded restraints or seclusion and thus potential harm to the patient.

Finding include:

1. Review of hospital policy titled "Rights and Responsibilities", dated reviewed 4/19/2017, lacked evidence of patients to be informed of their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

2. Review of hospital document titled "Know Your Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, lacked evidence of patients informed of their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

3. During an interview on 6/12/2018 at 7:45 AM, Staff A, Director of Community Benefits and Patient Relations, confirmed the Patient Rights Policy and the document provided to patient regarding their rights lacked evidence of patients informed of their right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

Based on document review and staff interviews, the emergency department (ED) nursing staff failed to timely remove Velcro locked restraints from an adolescent patient, according to physician order and in violation of hospital policy for 1 of 5 adolescent patient records reviewed (Patient #1).

Failure to ensure the nursing staff limited the Violent or Self-destructive (Behavioral) Restraint to the 2 hour maximum time for a vulnerable adolescent placed Patient #1 at risk for injury.

Findings include:

1. Review of the policy "Restraint and Seclusion", dated 10/26/2015, revealed in part, "Specific Provisions for Violent or Self-destructive (Behavioral) Restraint; Duration of Restraint/Seclusion Orders:.... shall remain in effect until the patient's behavior or situation no longer requires the use of restraint or seclusion, but no longer than: 2 hours for children and adolescents 9 to 17 years of age...."

2. Review of Patient #1's record revealed on 5/24/2018 Patient #1, 13 years old, was placed in Velcro restraints at 12:00 PM for all four extremities, bilateral wrists and ankles. An order was placed by the physician electronically on 5/24/2018 at 12:15 PM for "Restraints violent or self-destructive adolescent (9 to 17); Continuous x (times) 2 hours STAT (Latin for immediately)". The order reads "Comments: The duration should not exceed 2 hours. Please set the time to be at the time the restraints are initiated."

An ED Restraint Note dated 5/24/2018 at 1:59 PM revealed ED Physician C documented need for restraint or seclusion is: "No longer present."

Documentation revealed the restraints were fully discontinued at 2:43 PM. Restraints were not fully removed within the 2 hour maximum time limit, exceeding the limit by 43 minutes.

4. During an interview on 6/6/2018 at 4:24 PM, the Emergency Department Nurse Manager revealed the emergency department staff follow the hospital wide Restraint and Seclusion policy. The Emergency Department Nurse Manager confirmed the 12:00 PM - 2:43 PM 5/24/2018 restraint episode on Patient #1 exceeded the 2 hour maximum time frame as identified in the physician order and hospital policy for a patient 9 to 17 years old.