The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BARNES JEWISH HOSPITAL ONE BARNES-JEWISH HOSPITAL PLAZA SAINT LOUIS, MO 63110 Dec. 7, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy review, observation, record review and interview, the facility failed to:
- Promote a safe environment for patients admitted to the Behavioral Health Emergency Department (BHED) when staff allowed one (#6) patient admitted with suicide ideation (SI - thoughts for harming self) to go to the bathroom unescorted by staff. Refer to A-0144 for additional information.
-Ensure medical equipment/supplies were secured and not easily accessible to patients, admitted to the BHED with either SI or homicidal ideation (HI - thoughts of harming others), that could be used as ligatures for hanging or other items to harm self or others.
-Ensure cabinets located in the hallway of the BHED that contained linens, syringes, needles and various tubing were secured and not easily accessible to patients on the unit. Refer to A-0144 for additional information.
-Ensure that BHED rooms identified as psych safe rooms (rooms that had all medical supplies either taken out of the room and/or locked in a cabinet) had all medical supplies/equipment secured from patients assigned to those rooms. Refer to A-0144 for additional information.
-Ensure all BHED rooms were free of items that could be used as ligatures or other items that could be used to harm self or others. Refer to A-0144 for additional information

These failures by the facility placed all patients seeking care in the BHED at risk for potential poor patient outcomes.
The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient's Rights that resulted in a condition of Immediate Jeopardy (IJ).

As of 12/07/17, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:

-Immediate visual inspection/environmental check of rooms of ED patients currently designated as suicidal to validate risks are removed and other safety measures, as appropriate, are currently in place.
-Initial education will be provided to currently working ED Staff with roles involving direct patient care or services to patients in the designated behavioral health area: RNs, PCT/SNTs, EMT-Ps, Unit Secretaries, Public Safety; ED Physicians, NPs, and PAs; Nursing Office-Assigned Sitters; housekeeping staff assigned to the Emergency Department; ED Registration staff, prior to next shift until all staff are educated.
Education content to cover management of suicidal patients including providing a safe environment/use of checklist; maintaining patient observation at all times; treatment room alterations, and RN oversight.
-Upon arrival of suicidal/behavioral health patients to their ED exam room, the room will be assessed utilizing the Environmental Checklist by a charge nurse or a member of the ED leadership team.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and policy review, the facility failed to inform patients or patients representatives of the process to file a grievance (a formal or informal written or verbal complaint that is made to the hospital regarding the patient's care). This failed practice had the potential to affect all patients and had the potential to deny patients their right to a formal process to communicate and resolve grievances. The facility census was 918.

Findings included:

1. Record review of the facility policy titled, "Patient Complaint Management and Grievance Policy," Reviewed/revised 12/ 2015 showed the following:
- "Concern" is defined as an issue that does not require significant investigation and can be immediately corrected by the employee who first hears or receives the concern.
- "Complaint" is defined as an issue that requires some substantive investigation and does not have a readily identifiable or immediate solution.
- " Grievance" is defined as a documented Complaint that has gone through the complaint management process but was not satisfactorily resolved according to the complainant.

2. Record review of the facility policy titled, "Patient Rights Policy," reviewed/revised 02/2017 showed the following:
- Inpatients will receive a copy of the Hospital Patient Guide which contains the Patient Rights and Responsibilities.
- Out patients are offered a copy of Patient Rights and Responsibility statement during the check in process.
- As a patient, you have the right to voice concerns about the care you receive.
- Please share your concerns with your doctor or nurse and/or you may submit your concerns in writing.
- You can also share your concerns with the following groups: Missouri Department of Health and Senior Service, Missouri Protection & Advocacy Services and the Joint Commission Office of Quality Monitoring.

3. Record review of the Patient Admission Booklet provided by the facility and given to each patient who is admitted showed that as a patient, you have the right to voice concerns about the care you receive. Please share your concerns with your doctor or nurse and/or you may submit your concerns in writing.

The Patient Rights Policy or the Patient Admission Booklet did not give direction to patients or the patient's representative on the process of how to file a grievance.

During an interview on 12/04/17 at 2:10 PM Staff Q, Manager Patient Safety, stated that the word "concern" used in the Patient Rights pamphlet referred to the complaint/grievance process.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on interview, policy review and record review, the facility failed to provide patients or patients representatives with the information needed to submit grievances. This had the potential to inadequately resolve and properly identify grievances and potentially affect all patients. The facility census was 916.

Findings included:

1. Record review of the facility's policy titled, "Patient Complaint Management and Grievance Policy," Reviewed/revised 12/ 2015 showed the following:
- "Concern" is defined as an issue that does not require significant investigation and can be immediately corrected by the employee who first hears or receives the concern.
- "Complaint" is defined as an issue that requires some substantive investigation and does not have a readily identifiable or immediate solution.
- " Grievance" is defined as a documented Complaint that has gone through the complaint management process but was not satisfactorily resolved according to the complainant.
- A formal "complaint" can be filed by phone, mail, in person, etc. (This is contrary to the direction of the regulation through the interpretive guidelines)
- The person who receives the complaint will listen to the complaint and forward to Office of Patient and Family Affairs for documentation purposes prior to the investigation process beginning.
- Office of Patient and Family Affairs will enter the complaint into the facility's Complaint Management database for documentation and tracking purposes. An acknowledgement will be sent to the complaint within three days.
- Upon completing an investigation, the department manager must enter their findings into the complaint database.
- The department manager will draft a letter that includes the facility contact name, apology, steps taken to investigate, results of the investigation, date of actions, and offer the facility Patient Grievance process as an additional alternative if necessary.
- All complaints are expected to be "closed", within twenty one (21) calendar days of the date of the complaint was originally received.

2. Record review of the undated facility policy titled, "Executive Summary of the BJH Complaint Management and Patient Grievance Policy" showed that a grievance is defined as a documented Complaint which has gone through the complaint management process but which was not satisfactorily resolved according to the complainant.

The complainant is not informed until the final resolution letter is sent by the facility that there is a grievance process or how to submit a grievance.

3. Record review of the facility report titled, "State Report with Categories" showed that 210 complaints had been made between 06/04/17 and 12/04/17 of which some were e mails and/or written (which are directed by the regulations as being grievances)

4. Record review of the facility grievance report showed one grievance in the last six months.

During an interview on 12/07/17 at 2:10 PM Staff Q, Manager Patient Safety, stated "What we call complaints, you call grievances". She stated that written, emailed or complaints made in person, received after the patient is discharged are still complaints and not grievances. She stated that the direction for those to be complaints are not in the regulation but in the interpretive guidelines of the State Operations Manuel.

During an interview on 12/04/17 at 11:12 AM, Staff T, Director of Quality Management" stated that everything is a complaint even if it is an email or written.

The facility does not provide the patient or the patients representative a explanation of the grievance process. The facility speaks to "concerns" in the information provided to patients or patients representatives. Patients are not informed what a grievance is or how to submit a grievance.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on interview, record review and policy review, the facility failed to specify time frames for review of complaints and the provision of a response for seven patients (#13, #14, #15, #16, #17 #18, and #19) of seven patient complaints reviewed. This practice had the potential to affect all patients that filed a complaint causing the complainant to be unaware of the status of their complaint. The facility census was 916.

Findings included:

1. Record review of the facility policy titled, "Patient Complaint Management and Grievance Policy," Reviewed/revised 12/ 2015 showed
- "Complaint" is defined as an issue that requires some substantive investigation and does not have a readily identifiable or immediate solution.
- A formal "complaint" can be filed by phone, mail, in person, etc.
- The person who receives the complaint will listen to the complaint and forward to Office of Patient and Family Affairs for documentation purposes prior to the investigation process beginning.
- Office of Patient and Family Affairs will enter the complaint into the facility's Complaint Management database for documentation and tracking purposes. An acknowledgement will be sent to the complaint within three days.
- Upon completing an investigation, the department manager must enter their findings into the complaint database.
- The department manager will draft a letter that includes a facility contact name, apology, steps taken to investigate, results of the investigation, date of actions, and offer the facility Patient Grievance process as an additional alternative if necessary.
- All complaints are expected to be "closed", within twenty one (21) calendar days of the date of the complaint was originally received.

2. Record review of the Patient #13's complaint showed:
- The complaint was received by telephone on 11/01/17 at 9:45 AM.
- The letter of acknowledgement dated 11/01/17 to the guardian did not specify when the complaint would be reviewed or a response given.

Patients or the patient representative would not be aware of the status of their complaint/grievance.

3. Record review of the Patient #14's complaint showed:
- The complaint was received by telephone on 06/13/17 at 9:39 AM.
- The letter of acknowledgement dated 06/13/17 did not specify when the complaint would be reviewed or a response given.
- A response by letter to the patient was dated July 18, 2017

This response was sent 31 days after the complaint which is not timely.

4. Record review of the Patient #15's complaint showed:
- The complaint was received by telephone on 11/17/17 at 17:29 PM.
- The complainant requested to make a formal complaint (which is a grievance).
- The letter of acknowledgement dated 11/20/17 did not specify when the complaint would be reviewed or a response given.

This request was not acknowledged by the facility as a grievance as prescribed by regulation.

5. Record review of the Patient #16's complaint showed:
- The complaint was received by telephone on 11/30/17 at 9:26 AM.
- The letter of acknowledgement dated 11/30/17 did not specify when the complaint would be reviewed or a response given.

6. Record review of the Patient #17's complaint showed:
- The complaint was given in person by the patients guardian on 11/28/17 at 15:45 PM.
- The letter of acknowledgement dated 11/28/17 did not specify when the complaint would be reviewed or a response given.

7. Record review of the Patient #18's complaint showed:
- The complaint was given in person on 09/15/17 at 15:41 PM.
- The letter of acknowledgement dated 09/15/17 did not specify when the complaint would be reviewed or a response given.

8. Record review of the Patient #19's complaint showed:
- The complaint was given in person on 08/11/17 at 9:41 AM.
- The letter of acknowledgement dated 08/11/17 did not specify when the complaint would be reviewed or a response given.

During an interview on 12/04/17 at 2:10 PM, Staff Q, Manager Patient Safety, stated that when a complaint is received it is investigated and the patient or representative is sent an acknowledgement letter. After the investigation, a letter is sent within 21 days. She stated that there was no date (of possible resolution) in the initial acknowledgement letter to the complainant.

The facility failed to inform the patient or the patients representative of the time frames in the initial letter in which the complaint will be investigated and a response given to the patient if the resolution will not be in a reasonable time frame (usually seven days).
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, interview and record review, the facility failed to ensure all movies and/or videos used for entertainment on the Behavioral Health Unit (BHU) was screened for sexual/violence content for three pf three (#13, #10 and #4) patients that complained about inappropriate movies/videos that had been played on the unit. The BHU also admits registered sexual offenders to the unit. The facility also failed to ensure that one of one (#21) patient admitted to the Behavioral Health Emergency Department (BHED) had knowledge and gave his informed consented to being video monitored. These failed practices by the facility had the potential to deny patients of their basic right to respect, dignity, comfort and personal privacy. The facility census was 918, the BHU census was 10 and the BHED census was five.

Findings included:

1. Although requested on 12/05/17 at 10:45 AM, the facility failed to provide a policy related to the screening of Television and/or Movies.

2. Record review of Patient #10's current medical record showed he was admitted on [DATE] with complaints of unspecified schizophrenia and other psychotic disorders.

During an interview on 12/04/17 at 2:30 PM, the patient stated that:
- The facility provided movies on the unit for patients to watch in the evenings, weekends and holidays.
- The facility played regular TV shows during meals and throughout the day and evening.
- Some of the movies and TV shows were often too violent and had mild nudity at times.
- The Walking Dead was frequently on TV and the patient stated that he hated that show because he hated watching people get hurt.
- If he thought the movies playing on the unit were too violent or had too much nudity he would just go to his room.

3. Record review of Patient # 13's current medical record showed he was admitted on [DATE] with complaints of Schizophrenia. He was not able to communicate for an interview.

The patient's family had voiced concerns that the facility was playing a sexual movie with male and female nudity, having sex and with very graphic sex scenes that highly offended her. The family member stated she reported to the staff about the pornographic material that was on the TV and she felt that the staff ignored her complaint. The family member requested the staff call the administrator. The movie was ultimately taken out.

During an interview on 12/5/17 at 10:45 AM Staff D, RN Psychiatric Care Manager stated that registered sex offenders are admitted on the Behavior Health Unit (BHU). This movie that the staff played had the potential to negatively affect all patients seeking care in the BHU.

4. Record review of Patient # 4's current medical record showed he was admitted to the facility on [DATE] with complaints of psychosis.

During an interview on 12/04/17 at 3:30 PM, the patient stated that:
- The facility provided activities during the week, weekend and holidays.
- The facility provided movies on the unit for patients to watch in the evenings, weekends and holidays between 6 PM and 7 PM.
- Some of the movies played by staff on the unit were too sexual and violent for him.
- If he thought the movies playing on the unit were too sexual or violent he would not watch them.

This failure to screen video peior to playing it for patients, affects all BHU patients by exposing them to violent or sexual videos. This is not a therapeutic activity, particularly for sex offenders. This failure had the potential to cause harm to the patients or trigger sex offendersto harm other patients.

5. Record review of the facility's policy titled, "Responsible Use of visual Surveillance Systems," revised 06/2017, showed the directives for staff assisted by the use of visual surveillance technology:
-Visual surveillance technology must be used only to meet the facility's critical goals for security and safety, and must be used in manner sensitive to interest of privacy and expression;
- Signs will be posted in the patient care areas to inform visitors and patients of the use of video monitoring or recording; and
- Upon patient admission to a video monitored room, the nurse or designee will communicate to the surveillance equipment operator any special concerns.

Observation on 12/04/17 at 3:15 PM, in the BHED (Behavioral Health Emergency Department), showed rooms #3 through #11 with room #3 located at the end of one hall. The rooms were video monitored and the monitor screens were located at the monitoring station. Outside of the rooms were signs that communicated that the rooms were video monitored with exception of room #3.

6. Observation on 12/05/17 at 11:00 AM, in the monitoring station, showed live monitoring of BHED room #3 which showed full view of Patient #21.

During an interview on 12/05/17 at 11:05 AM, Staff Z, Patient Safety Assistant (PSA), stated that Patient #21 was a medical overflow patient and should have not been video monitored. She should have turned off the monitor to BHED room #3.

Record review of Patient #21's History and Physical (H&P), showed the patient was a [AGE] year old male with known abdominal aortic aneurysm (AAA, enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen) that presented to the facility for severe back pain. The patient was alert and orientated to person, place, and time.

Record review of his triage note on 12/04/17 at 11:45 PM, showed that the patient was alert and orientated to person, place and time. The patient had no learning needs and/or barriers identified.

Record review of the facility's internal communication on 12/05/17 at 2:03 AM, he was unable to sign consent, would not wake up, and no family present.

JBRecord review of his magnetic resonance imaging (MRI, powerful magnetic field to produce detailed pictures of internal body structures) screening, performed on 12/05/17 at 6:25 AM, showed the patient was not confused, lethargic, and/or disoriented.

JBRecord review of his consent and authorization, signed on 12/06/17 at 12:00 PM, showed the patient's consent "to taking and storing photographs, videos and other electronic images of me/my child for the purposes of treating me/my child and providing education and I understand that reasonable efforts will be made to protect the identity of me/my child."

During an interview on 12/05/17 at 11:05 AM, Staff BB, Registered Nurse (RN), stated that:
- She was responsible for Patient #21 in BHED room #3;
- She did not communicate to him that he was video monitored;
- There was no signage on BHED room #3 that instructed patients and visitors that the room was video monitored;
- Nurses communicated when video monitoring was to be initiated; however, the nurses did not communicate to terminate the video monitoring with discharge of a patient;
- HE did not require a video monitor related to the patient was a medical overflow, and
- BHED room #3 was video monitored for the previous patient, and the nursing staff failed to communicate with the PSA to stop the video monitor.

During an interview on 12/05/17 at 11:40 AM, Patient #21 stated that:
- He was unaware that he was in a video monitored room and was actively being monitored;
- No staff had communicated that he was video monitored; and
- It "bothered him" that no one told him he was being video monitored.

During an interview on 12/05/17 at 2:10 PM, Staff X, Lead House Supervisor, stated that:
- He was supervisor over PSAs;
- Privacy of the patients was a priority, and
- The nurses should communicate with the PSAs at all times for the use of video monitoring.

This failure affects all BHED patients assigned to rooms #3 through #11 for patients that received care in a setting which did not provide personal privacy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interviews, the facility failed to provide a safe environment for two (Patient # 6 and #22) patients in the Behavioral Health Emergency Department (BHED) with suicide ideations (SI - thoughts of harming self). Patient #6 had been in the unit approximately 48 hours (four 12 hour shifts) and during this time staff failed to remove from his room plastic trash bags, plastic laundry bags, an IV pole that was hanging down from the ceiling and a call light with a seven foot cable. These items left in the room could be used by the patient as ligatures to hang or suffocate him. Patient #22 was assigned to a room with easily accessible medical equipment/supplies that could be used as ligatures or items to harm self or others. Patient #22 exited his room and walked down the hallway without staff escort and entered the restroom. The facility census was 918 and the BHED census was three.

Findings included:

1. Record review of the facility's policy titled, "Emergency Department Policies/Procedures: Elopement (act or instance of running off secretly without permission)/Suicidal (thoughts of harming self)/Homicidal (thoughts of harming others) Precautions," dated 05/2017 showed directives for staff: All SI (Suicide Ideation)/HI (Homicidal Ideation) patients will be escorted to the restroom for direct observation during elimination or will be offered a urinal or bedpan. Security is available if additional support is needed.

2. Record review of the facility's policy titled, "Suicide Precautions," dated 10/2017 showed directives for staff:
-Dangerous items include but not limited to the following:
-Cords - such as shoe laces, draw strings, electrical appliances with cords over 9 inches, belts, neckties, suspenders, telephone cords or cell charger cords.
-Patient Safety Assistant (PSA) - is a designated sitter or staff person to sit with the patient continuously 1:1, who remains within an arms' length of the patient at all times. The PSA receives training provided by the facility. The PSA documents every 15 minutes on the "Patient Safety Observation Log" the patient's behavior and reports any pertinent information obtained regarding the patient to the RN (Registered Nurse) in a timely manner.
-Patients in rooms 5, 6, 7, 8, 9, 10, 11 and 12, and in the hall area surrounding these rooms monitored by a PSA/sitter.
-Inform PSA to call for help if patient is threat to harm self or others.

3. Observation of the ED on 12/04/17 at 3:10 PM showed 10 patients on the BHED, with Patient #6, that was SI, who was video monitored for safety. Patient #6 was the only patient assigned to BHED room #11.

Observation of BHED room #11 on 12/04/17 at 3:15 PM showed a removable suspended IV pole with ring, plastic trash liner, and an empty plastic linen bag.

Record review of Patient #6's History and Physical (H&P) showed a [AGE] year old male, (MDS) dated [DATE] at 2:42 PM. The patient had a history of bipolar (brain disorder that causes shifts in person's mood), alcohol abuse, and active SI. The patient noted a depressed mood, anhedonia (inability to experience pleasure from activities usually found enjoyable), insomnia (inability to sleep), and had six to seven prior suicide attempts, with the last shortly after his wife passed in July. The patient had gone to numerous facilities recently, been hospitalized as an inpatient, and was discharge from another facility on 12/01/17.

Record review of his psychiatric consult note on 12/02/17 at 11:17 PM, showed recommendation/plans and interventions that the patient was appropriate for voluntary psychiatric admission, either at the facility, and/or outside facility. The staff should continue standard suicide, elopement and assault precautions.

Record review of his BHED patient safety observation log from 12/02/17 through 12/04/17 showed that staff had attested by signing every 15 minutes for Patient Safety Assistant (PSA), and one hour for nursing, that the environmental safety checks were performed including:
- Bed low and locked;
- No sharp/harmful objects within patient reach;
- Call light at bedside; and
- Unobstructed view of patient.

Record review of his PSA communication tool showed that:
- The patient was S-2 suicidal precautions;
- Had suicidal and harmful behaviors; and
- Risks that remained in the patient's BHED room were scrubs and linen.

Record review of his medical record showed that the patient was admitted to the facility's inpatient psychiatric unit on 12/04/17 at approximately 5:33 PM.

During an interview on 12/04/17 at approximately 3:15 PM, Staff M, Clinical Practice Specialist, stated that:
- The removable suspended IV pole with ring was a ligature risk;
- The plastic trash liner and the plastic linen bag should have been removed from the room; and
- All nurses had training on these items, and will say that the items should have been removed from Patient #6's BHED room.

During an interview on 12/04/17 at approximately 3:20 PM, Staff K, Registered Nurse (RN), stated that:
- She was the responsible nurse for Patient #6;
- She signed Patient #6's BHED patient safety observation log showing she had performed environmental safety checks;
- She had training on removing the suspended IV pole with ring, and plastic bags from suicidal patient's BHED rooms; and
- The removable suspended IV pole with ring, and the plastic bags, should not been left in Patient #6's BHED room.

During an interview on 12/05/17 at 2:35 PM, Staff N, Clinical Nurse Manager, ED Services, stated that nurses sign the BHED patient safety observation log and environmental safety checks. By signing off, the nurses were attesting that the room was safe including cords, IV poles, and plastic bags.

4. Record review of Patient #22's current BHED record showed he (MDS) dated [DATE] at 9:27 AM per Emergency Medical Services (EMS) for complaints of SI.

Record review of the patient's Emergency Department Patient Safety Observation Log undated showed staff assessed that the patient required Suicide Precautions (S2).

Record review of the patient's Patient Safety Assistant (PSA) Communication Tool dated 12/05/17 showed:
- Type of Precautions: S2-Suicidal;
- Behaviors to Monitor: Self harm; and
- Risks that Remain in the Patient's Room: Scrubs, bench, food and drink.

5. Observation on 12/05/17 at 9:55 AM showed BHED Room #6 that Patient #22 had been assigned showed the following:
- The room was identified by staff as being a psych safe room (a room that has a garage like door that can be brought down to keep medical items/equipment from being accessible to patients) with the secured garage like door in the up position all medical equipment/supplies were accessible to the patient.
- With the door being in the up position the following items were easily accessible to the patient:
- Suction tubing (hooked to a suction canister, used to clear the airway of blood, saliva or other secretions to assist with breathing) hooked up to a canister that was approximately three foot in length.
- 13 pulse oximeter (instrument used to monitor oxygen levels) cords approximately 12.5 inches long.
- Telemetry (machine used to monitor cardiac/heart function) leads.
- Various needles and equipment to start intravenous lines (a needle placed into a vein used to administer medications, fluids and nutrition).

The various tubes, cords, and medical supplies were easily accessible to the patient while in the room. The various medical tubes and cords could serve as a ligature to hang oneself that had SI or hurt others if the patient had HI. The various other supplies accessible in the room could be used by a patient to harm self with SI or others if the patient had HI.

Observation on 12/05/17 at 9:55 AM showed various carts in the hallway by BHED Rooms #5, #6, #7 and #8 that had various medical supplies/equipment/linens that were easily accessible to patients assigned to those rooms.

Observation of the BHED on 12/05/17 at 10:15 AM, showed Patient #22, a patient that required suicidal precautions, exited BHED room #6, ran down the hall unescorted, entered the restroom, closed the door, and was out of view of any staff and/or this observer.

Observation on 12/05/17 at 2:30 PM showed BHED Room #11 had the following items easily accessible to patients that would be assigned to the room:
- A call light cord approximately seven foot in length.
- Telemetry leads.
- Telephone cord approximately 15 foot in length.
- Three cabinet doors above the sink were not secured and contained various medical supplies and equipment that a patient could access and use to harm self or others.

During an interview on 12/05/17 at 9:55 AM, Staff V, RN, Interim Director Clinical OPS, ED, stated that the patient sitting in the hallway in a chair (Patient #22) could have access to everything in BHED Room #6 (the garage like door was in the up position with all items easily accessible to the patient or others in the BHED).

During an interview on 12/05/17 at 10:10 AM, Staff Y, PSA, stated that:
- She was currently monitoring four patients in the BHED per video.
- She was able to monitor up to four patients at a time per video monitoring.
- She monitored patients admitted with SI, behavior issues, medical concerns and detoxing from alcohol and drugs.
- She would alert ED staff if a patient was starting to fidget with blankets/sheets, hurting themselves by banging their head on the wall or hitting the wall with their fists.
- She was not only watching the patient but also monitoring the environment for any hazards in the room that a patient could use to harm them or staff.
- She was not allowed to leave the video monitoring area unless she was relieved by another BHED staff because patients had to have constant visual video monitoring by the PSA.

During an interview on 12/05/17 at approximately 10:35 AM, Staff U, RN, stated that Patient #22 was on suicidal precautions and that the PSA did not notify her that the patient had left his BHED room and entered the restroom.

During an interview on 12/05/17 at 10:50 AM, Staff Z, PSA, stated that she was unaware that Patient #22 was in his BHED room. She did not page the nurse and/or security that the patient left his BHED room.

During an interview on 12/05/17 at 10:50 AM, Staff KK, Performance Improvement Specialist, stated that Patient #22 exited out of BHED room #6. The PSA should have notified the nurse.

During an interview on 12/05/17 at approximately 11:10 AM, Staff E, Security, stated that he had seen Patient #22 run down the hall toward the restroom and out of view. The PSA did not notify him that the patient had exited his BHED room.

During an interview on 12/05/17 at 2:10 PM, Staff X, Lead House Supervisor, stated that:
- There was no video monitoring in the restroom;
- A SI patient would be out of view when entered the restroom; and
- The PSA should notify the nurse first, then security when a patient was not able to be viewed.

During an interview on 12/05/17 at 2:30 PM, Staff N, RN, Clinical Nurse Manager, ED Services, stated that:
- The expectation was that the nurse taking care of a patient was to ensure the room/environment was safe.
- The nurse taking care of the patient was to make environmental rounds during their 12 hour shift.
- Staff that made rounds does not document the environment rounds.
- The call light (approximately 7 foot long cord) was left in Patient #22's BHED Room #6 (the patient was admitted due to SI).
- The same call light system (with the approximate 7 foot long cord) was used for all patients in the BHED.
- Patient's on suicide watch/precautions are to have staff escort with them when they go to the restroom.

During an interview on 12/05/17 at 2:35 PM, Staff N, Clinical Nurse Manager, ED Services, stated patients that were SI should have an escort to the restroom.

These failed practices by BHED staff to provide a safe environment increased the risk for all patients admitted with SI and/or HI for potential harm to self or others, these easily accessible various medical equipment/supplies were available for use as ligatures or items to harm self or others.