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.

CHRIST HOSPITAL 2139 AUBURN AVENUE CINCINNATI, OH 45219 May 4, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, staff interview, medical record review, policy review, and review of incident reports, it was determined the facility failed take appropriate and immediate action to ensure all patients received care in a safe setting on the behavioral health unit (A144). The systemic effect of these practices resulted in the facility's inability to ensure the safety of all patients admitted to the facility for psychiatric services. The behavioral health unit census was twenty two patients and six of the twenty two patients were assigned to the behavioral health intensive care unit.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, observation, staff interview, review of incident reports, and policy review the facility failed to ensure all patients admitted to the behavioral health unit received care in a safe setting. This affected eight (Patients #1, #2, #3 #4, #5, #6, #8 and #9 ) of ten medical records reviewed. This had the potential to affect all twenty-two patients admitted to the unit for psychiatric services.

Findings include:

Review of the policy titled "Patient Rights and Responsibilities of Behavioral Health Patients" Policy Number 6.2.113 (revised 11/15) states each patient has the right to reasonable protection from assault or battery by any other person. Review of the behavioral health packet each patient receives upon admission includes the right to be treated with dignity and respect, the right to a current, written, treatment plan, and the right to reasonable protection from physical or emotional abuse or harassment.

1. Review of the medical record for Patient #3 revealed an involuntary admission to the behavioral health intensive care unit on 04/26/17 following evaluation in the emergency department for acute psychosis. The patient's psychiatric diagnoses included mood disorder, questionable bipolar disorder, and personality disorder. The patient was admitted to the Behavioral Unit until 04/26/17 at 5:26 PM. The patient was admitted to room 6074 in the behavioral health intensive care unit (BICU) following psychiatric evaluation.

Per interview of Staff A on 05/03/17 at 12:33 PM, Patient #1 and Patient #3 were found to be engaged in sexually inappropriate behavior on the behavioral health intensive care unit (BICU) on 04/28/17 at approximately 1:20 PM, Patient #1 placed his mouth on Patient #3's breast.

No incident report was documented and/or interventions put in place following this incident.

2. Review of the medical record for Patient #1 revealed an involuntary admission to the behavioral health intensive care unit (BICU) on 04/26/17 following evaluation in the emergency department (ED) for suicidal ideation. The Psychiatric Physician's History and Physical revealed the patient had a psychiatric history significant for schizophrenia with a previous psychiatric hospitalization .

The patient was admitted for safety concerns, monitoring, and stabilization. Patient #1 was admitted to room 6070 on 04/26/17 at 9:50 PM on the behavioral health intensive care (BICU) unit and moved to room 6071 on 4/27/17 at 8:02 PM. Patient #1 was exhibiting aggressive unstable behaviors while admitted to the (BICU) unit.

The medical record noted hypersexual behaviors on 04/28/17 at 10:11 AM with no interventions in place. Patient #1 also had documented urinary incontinence that lacked treatment plan interventions.

3. Review of the medical record for Patient #2 revealed an involuntary admission to the behavioral health unit on 04/04/17 following evaluation in the emergency department. The patient resided in a long term care facility and was becoming increasingly agitated and aggressive towards staff, refusing medications, and exhibiting symptoms of depression. The psychiatric diagnoses included schizoaffective disorder, anxiety disorder, and personality disorder. The probate court appointed a guardian on 05/05/16 due to the patient being incompetent.

The medical record revealed the patient exhibited ongoing manic behaviors and was sexually inappropriate at times on the unit and assaulted staff. On 04/28/17 at 9:09 PM the patient was assigned to room 6074, on 04/29/17 at 2:31 PM moved to the geriatric unit room 6060, and on 05/03/17 at 6:56 PM the patient was moved to room 6061.

Review of the incident reports dated 04/29/17 at 7:30 AM revealed Patient #2 was found in the room of Patient #1 and both were engaged in sexual intercourse. Staff B and C stated in an interview on 05/03/17 at 10:36 AM the patient care assistant was conducting 15 minute checks on the behavioral health intensive care unit and was unable to locate Patient #2. The patient was found in Patient #1's room engaged in sexual intercourse. The incident involving the two patients was reported to all administrative staff and investigated.

An interview was conducted with Staff A on 05/03/17 at 10:55 AM who reported getting a phone call on 4/29/17 by the charge nurse with regard to the incident. The staff was conducting 15 min checks on the unit and a female patient was found in a males room engaged in sexual intercourse. The charge nurse notified the physician, sexual assault nurse examiner (SANE), and Risk Management. When the (SANE) nurse arrived both patient's became agitated, refused assessment, and denied sexual intercourse occurred. The (SANE) nurse notified the physician and the Police Department.

The care plan for Patient #2 lacked interventions when the patient was moved to the geriatric unit after the above incident. The medical record lacked individual care planned interventions to ensure the safety of the patients on the unit.

Following the incident between Patient #2 and Patient #1, Patient #1 was placed on 1:1 observation and was administered as needed psychotropic and anti- anxiety medications on 04/29/17; however, review of the staffing level for the unit lacked documentation of the ongoing 1:1 observation.

The facility moved both females (Patient #2 and #3) involved in both incidents described by psychiatric staff as sexually inappropriate to the geriatric area of the psychiatric unit and were placed in a semi-private room as roommates. Both medical records lacked individual care planned interventions to ensure the safety of the patients on the unit.

Observation on 05/04/17 at 9:50 AM revealed the patients (#2 and #3) were moved to separate rooms.

Upon request the facility lacked policy and procedures for sexually inappropriate behaviors within the psychiatric unit. The facility lacked policy and procedure for when to initiate and/or discontinue the 1:1 observation level. The facility failed to develop individualized care plans and provide interventions when sexually inappropriate behaviors are identified. These findings were confirmed with administrative staff throughout the survey and


Review of the facility policy titled Suicide Risk Assessment and Precautions (Policy #6.3.112) on 05/04/17 at 4:30 PM revealed a patient with a modified SAD PERSONS score of a six or higher revealed a potential risk for suicide. The policy instructed staff to implement suicide precautions protocol. It was further noted that a RN is to complete the initial check and at least one check every two hours on the observation flowsheet.

The observation flowsheets to be used for suicidal patients per policy lacked documentation the RNs completed the initial and every two hour checks on Patients #4, #5, #6, #8, #9, #1 and #3.

4. Patient #4 (MDS) dated [DATE] at 09:48 AM with a complaint of suicidal ideation and requested psychiatric evaluation. The patient reported hearing voices telling him/her that he/she was "just a piece of" When ED staff asked him/her if he/she had a current plan for suicide, he/she stated, "I don't have a plan but I could figure out something." The patient's SAD PERSONS score at 10:02 AM was an 11. Suicidal precautions were initiated in the ED.

The patient was placed on 1:1 supervision and the Suicide Assessment flowsheet was completed by an RN every 15 minutes. The patient was admitted to the Behavioral unit at 1:24 PM where suicidal precautions continued. The initial check on the observation flowsheet, however, was completed by a PCA. The SAD PERSONS score assessed by Behavioral staff at 2:45 PM was 14. A Behavioral unit PCA continued to document the 15 minute checks until 11:30 PM. A nurse's note at 2:15 PM on 04/25/17 revealed a staff PCA observed a sheet hanging over the patient's bathroom door that morning and had a suspicion the patient may be trying to harm him/herself.

The PCA left the room but looked through the peep hole in the patient's door and saw the patient moving a chair over to the bathroom door in an attempt to hang self. The PCA immediately went into the room and stopped the patient before the patient could follow through with the plan. The patient was medicated with 1 mg Ativan (anti-anxiety medication) by mouth and monitored 1:1 in the lounge until a bed was made available in the Behavioral Health Intensive Care Unit (BICU). The observation flowsheet continued to be checked every 15 minutes by staff PCAs without the RN check every two hours.


5. Patient #5 was transported directly to the Behavioral unit from an outside hospital on [DATE] at 05:23 AM after being found by police jumping in front of cars in an attempt to kill him/herself. The patient stated he/she didn't have anything to live for. In the ED the patient's SAD PERSONS score was 19 and suicide precautions were implemented. The observation flowsheet, however, revealed staff PCAs completed the required 15 minute checks.


6. Patient #6 (MDS) dated [DATE] at 04:00 AM after attempting suicide by lying in the middle of the street. The Psychiatrist's History and Physical revealed the patient was almost hit by a car. It was further noted the patient had a history of past psychiatric hospitalization s with diagnoses of substance induced mood disorder and suicide attempts. The patient's SAD PERSONS score ranged from 17 to 19. The observation flowsheet revealed the PCA again, completed the 15 minute safety checks for suicidal patients with only occasional checks by staff RNs.


7. Patient #8 (MDS) dated [DATE] at 11:37 PM. A note revealed the patient had a history of multiple admissions since January, 2017. It was further noted the patient was suicidal with a plan to overdose. The patient's SAD PERSONS score was 15 at 11:47 PM and the patient was placed on suicidal precautions. Patient #8 was transferred to the Behavioral Unit at 11:23 AM on 04/06/17. The observation flowsheet lacked documentation an RN ever checked the required form for suicidal patients until 04/08/17 at 3:15 PM.


8. Patient #9 (MDS) dated [DATE] at 11:03 PM with complaints of both suicidal and homicidal ideation. The patient's SAD PERSONS score was 12 and he/she was placed on suicidal precautions. The patient was admitted on [DATE] at 01:13 PM. Review of the observation flowsheet revealed an RN had not checked the required form for suicidal patients his/her entire hospitalization . The patient was discharged home on 04/18/17 at 11:43 AM.


9. Patient #1's medical record revealed a Modified SAD PERSONS (Suicide Assessment tool) score of 19 in the ED. The record revealed the patient did have a suicide plan. Suicidal precautions were initiated in the ED. The patient was admitted on [DATE] at 9:50 PM. Although the score was reduced to 14 at 11:07 PM, after the patient denied having a specific plan to commit suicide, the score remained greater than six and suicidal precautions continued. Review of the observation flowsheet revealed the initial assessment was completed by a staff patient care assistant (PCA), not an RN. There were no initials by a nurse until more than 24 hours later, at 11:30 PM on 04/27/17. Initials of the RN were noted again at 11:45 PM. The form was not initialed again until 11:30 PM on 04/28/17.


10. Review of the medical record for Patient #3 revealed an involuntary admission to the behavioral health intensive care unit on 04/26/17 following evaluation in the emergency department for acute psychosis. The patient's psychiatric diagnoses included mood disorder, questionable bipolar disorder, and personality disorder. The initial SAD PERSONS score at 11:30 AM in the ED was six. The patient was not admitted to the Behavioral Unit until 04/26/17 at 5:26 PM. At 6:00 PM a staff member (PCA) documented the initial check on the observation flowsheet. The initials every 15 minutes remained that of Behavioral staff PCAs through 7:15 AM on 04/27/17, more than 10 hours later.


Staff A, Nurse Manager of the Behavioral Health Unit, was interviewed on 05/04/17 at 5:15 PM. According to Staff A, all patients admitted to any unit of the hospital expressing an emotional concern are assessed for their risk of suicide using the Modified SAD PERSONS scale. This scale is a suicide risk assessment calculated through evaluation of 10 factors (sex, age, depression level, previous suicide attempts, excessive alcohol or drug use, rational thinking loss, single or widowed or divorced, organized or serious attempt, no social support and stated future intent). Staff A explained that a score of 6 or more indicates an increased potential suicide risk and staff are required to implement suicide precautions. Suicidal precautions on all units of the facility except the Behavioral unit include supervision using a one staff to one patient (1:1) ratio, removal of harmful items such as cords and belts from the room, and in some instances, placing patients in paper gowns. Staff A revealed that when a Behavioral unit patient is determined to be a higher risk for potential suicide, a registered nurse is required to complete an initial check on the facility observation flowsheet, then an ongoing check every two hours. Staff A stated a patient care technician (PCA) is permitted to complete the observation flowsheet for all other checks.

The facility failed to ensure the suicide risk assessment and precautions policy and procedure was followed on the behavioral health unit.

Staff A was interviewed on 05/05/17 at 12:30 PM. It was confirmed that the observation flowsheets of Patients #4, #5, #6, #8, #9, #1 and #3 lacked documentation the RNs completed the initial and every two hour checks on suicidal patients as required by this policy.