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.

TENNOVA HEALTHCARE-CLEVELAND 2305 CHAMBLISS AVE NW CLEVELAND, TN 37311 April 18, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 8 patients reviewed for restraints/seclusion.

The findings included:

During the survey it was found Patient #1 presented to the Emergency Department (ED) on 3/21/17 after a fall. Further review revealed the patient had a psychiatric evaluation performed while in the ED resulting in an involuntary inpatient commitment due to delusional and manic behaviors. Continued review revealed the patient had a history of Bipolar Disease and Alcohol Abuse. On 3/23/17 the ED staff found a lighter in the patient's belongings which was removed by the staff and the patient was placed on one on one (1:1) observation with a security guard/sitter. Further review revealed the patient had another lighter under his gym shorts, not found by the staff, and the patient used the lighter to start a fire in his room on 3/23/17 at 3:36 AM.

During a conference on 4/18/17 at 10:50 AM, in the Chief Quality Office, with the Chief of Quality Officer and the Administrator, the facility was informed of an Immediate Jeopardy (a situation in which the providers noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13 (condition).

Review of a Departmental Memo sent from the Nurse Manager to the ED Staff and Security dated 3/23/17 revealed "...the following will go into effect immediately:
1. Security is to be notified upon arrival of all behavioral health patients. The patient and all belongings will be searched by staff and security.
2. Security will use a metal detector wand in efforts to remove any objects from the patient that could cause harm to self or others. Patient searches will be documented in the patient's medical record and security report.
3. Patients will be asked to empty contents from all pockets.
4. The patient's nurse or team leader will ask the patient for permission to "pat down" their exterior after being scanned with the wand.
5. Patient's possessions will be searched and any high risk items such as sharps, lighters, high heels will be inventoried, bagged and tagged and locked in the cabinet in the equipment room; this will be documented in the medical record.
6. All behavioral health patients will be searched by staff and security upon presentation, at each shift change, and after visitation.
7. Behavioral health patients will be placed in a gown when placed in seclusion or as indicated based on assessment of patient risk. At that time all items will be removed from their person and room.

Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following were implemented:
(1) the facility began conducting an internal review of the incident on the date it occurred (3/23/17) and developed an initial plan.
(2) the facility self-reported the fire incident on 3/24/17 to the State of Tennessee. The Chief Executive Officer (CEO) notified the Chief Nursing Officer (CNO), Chief of Staff, General Medical Staff, Medical Executive Committee, and the Board of Trustees Chairman of the fire incident. Hospital managers were notified on 3/23/17 during a safety huddle. The Chief Quality Officer (CQO) notified the Quality Improvement Committee.

Immediate Action Plan
The CEO, CNO, CQO, RM (Risk Manager), ED Director, and the Security Director determined there was a need for an enhanced plan for patients identified as being at risk for suicide or behavioral health issues.
ACTION (1) an analysis was completed on the date of the occurrence and indicated changes in policy were needed.

Staff Education
The CEO, CNO, CQO, RM, ED Director, and the Security Director determined staff should receive immediate education on the policy and memo. Education begun on 3/23/17 and is ongoing. In addition, the ED Director and the Security Director educated staff present on 4/18/17 on the policy as well as an example of flow sheets. In addition, all staff involved with suicidal or behavioral health patients will receive education by 4/30/17 via a Power Point. The Power Point education will begin immediately (4/18/17). Directors will ensure education is completed via logging completed tests on the employee roster(s). In addition, staff who have been off will report to their supervisor or the Associate Director of Nursing Services (ADNS) upon returning to work and will be provided the education and tests, which must be completed and given back to their manager before starting their shift. ADNS will receive their training beginning 4/18/17 and will follow the above process if they have been off.

Physician and Allied Health Education
Physicians were educated on the event and policy at the general staff meeting on 4/11/17. This will also occur at the 4/20/17 Medical Executive Meeting.

Board Education
The board will be educated on the policy and the event on April 15, 2017.

Review of a Power Point Presentation dated 4/18/17 revealed the following topics were presented for staff education:
1. Acuity Level Explanations and Interventions regarding the supervision and monitoring of Suicide and Behavioral Health patients.
2. Suicide and Behavioral Disorder Assessment.
3. General Safety "...Interventions...clinical status and patient safety documented every 15 minutes for acuity 1, 2, 3 patients; ensure a safe environment: complete Psych-Safe room checklist...remove all personal belongings from the room and secure...search belongings brought in by visitors for any harmful items..."
4. Review of the required documentation for Suicide or Behavioral Health patients.
Further review revealed upon completion of the Power Point presentation, a post-test completion was required for all staff.

Review of an Educational Attendance Record dated 4/18/17 revealed the security officers and maintenance staff were given education regarding the "Search of Behavioral Health Patients in the ED."

Review of an Educational Presentation "Behavioral Health Observation Education" dated 4/2017, revealed ED staff were given education regarding the following topics:
(1) Documentation (behavorial health observation sheets) is to be completed on paper forms
(2) Patients should receive a "...complete assessment by the primary RN [Registered Nurse] every shift and as needed according to behaviors. Assessments can only be completed by an RN...should be completed at the beginning of the nurse's shift and could coincide with the search and wanding...assessment should be documented on paper but also noted in the chart..."
(3). Documentation will be done as specified:
A. Continuous 1:1 patient to observer
1.Patient is to be continiously monitored but documentation of assessments need to be made every 15 minutes by hospital staff who have completed competency.
2. RN to document assessment every hour on Patient Observation Form.
B. Continuous Visual Surveillance:
1.Ratio may be more than 1:1 but patient is under direct visual observation
2. Observer must be able to attend immediate needs of patient without risking surveillance of the other.
3. Documentation every 15 minutes by hospital staff who have completed competency.
4.RN to document assessment every hour on Patient Observation Form.
C. Close Observation
1.Patient may not be left alone without support person (can be reliable family or friend)
2.Observation is required by hospital staff at a minimum of every 15 minutes.
3.Documentation every 15 minutes by hospital staff who have completed competency.
4.RN to document assessment every hour on RN assessment form.
D. Intermitted Observation:
1.Documentation every 30 minutes by hospital staff with RN documentation.
2.RN to document assessment every hour on Observation Form.
E. Any change from above should be accompanied by an order/suicide risk behavior disorder assessment signed by the physician PRIOR to the change.
1.Take form to the appropriate physician but do not leave it with the physician.
2.Have the physician to sign immediately and return to the chart.
3. Ensuring all documentation is completed is the responsibility of the RN.
4.If a sitter is present then ensure all documentation is completed accurately.
5.Licensed Practical Nurses (LPN) can be used as sitters but cannot chart assessments.
6.Every hour the RN must document on the Patient Observer Monitoring Checklist and in the Electronic Medical Record (EMR) as a nursing note.
(5) If the patient is placed in seclusion or restraints then a Nursing-Violent/Self Destructive Restraints and or Seclusion flow must be completed by the RN. This will accompany the Patient Observation Form.

Review of an Educational Attendance Record dated 4/18/17 revealed the ED Director initiated training for the ED staff related to Behavioral Health Observations.

Review on the Behavioral Health Plan of Action for the ED dated 4/2017, revealed the following:
(1) ED Director will develop a database to track ED employees for completion of both educational presentations.
(2) 100% real time chart checks will begin by Team Leads on 4/18/17.
(3) 100% chart audits to ensure compliance and understanding of training will begin by Assistant ED Manager on 4/19/17.
(4) Any deviations from standards will be forwarded to and addressed by ED Director.

Review of an Electronic Media (e-mail) dated 4/18/17 at 4:44 PM sent from the Administrator to the Senior Management staff revealed:
(1) All ER Staff and Providers must review the Power Point Presentation and take the test under Education on the website for Suicide Risk Behavioral Disorder Assessment.
(2) Any individuals who will be assigned as sitters (security or clinician) responsible for any of these patients throughout the hospital must also complete the power point presentation and corresponding test.
(3) Employees should print off validation they have completed the test and submit to their manager.
(4) Managers need to maintain a log of who and when the reviews and tests occurred.
(5) Anyone failing to take the test by April 30, 2017, will be suspended until such time the test is completed.
(6) Additionally any log for 15 minute checks or hourly checks on Behavioral Health or suicide patients MUST be completed in its entirety. This is for everyone's safety. Failure to do so can result in disciplinary action.

Interview with the CQO on 4/18/17 at 12:30 PM, in the CQO's office, revealed the facility had implemented a mandatory Power Point related to Behavior Health patients and training had already started. Further interview revealed "...all employees who serve or may serve in a sitter role will be required to complete the training...all ED staff and security personnel will be required to complete the training prior to sitting with any patient...the ED Director will ensure this compliance on a daily basis..." Further interview revealed "...the administrator will send the required information to all of the Directors...each director has an employee roster and they will be responsible for ensuring all of their employees complete the training within the required time frame...this information will be presented in the Quality meetings, the medical executive meeting, and to the Governing Board..."

During a conference with the Chief Quality Officer, Administrator, Chief Quality Officer, ED Nurse Manger, and the Assistant Chief Nurse Officer (ACNO) on 4/18/17 at 4:05 PM, in the CQO's office, the facility presented an Immediate Action Plan for the Immediate Jeopardy. Review of the Action Plan revealed immediate actions were implemented by the facility. The Immediate Jeopardy was removed on 4/18/17.

Refer to Standard A144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 8 patients reviewed for restraints/seclusion.

The findings included:

Review of facility policy "Suicide Risk Assessment and Reassessment for Behavioral Health Services" last revised on 3/27/16 revealed "...all patients have the right to be cared for in a therapeutic environment that will promote accurate identification of patients who are at an increased risk for suicide or self-destructive behaviors..." Further review revealed "...items which present a danger to patients should be removed...personal searches: conducted at the initiation of line of sight and prior to any increase in observation level..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] at 4:06 PM after a fall. Further review revealed the patient was transferred to an inpatient psychiatric facility on 3/24/17.

Medical record review of an Emergency Department (ED) Quick Triage assessment dated [DATE] at 4:17 PM revealed "...pt. [patient] arrested at 1058 [10:58 AM] for public intoxication, c/o [complains of] fall and struck head, then went unresponsive in jail...per police..." Further review revealed "...level of consciousness: alert, cooperative, not oriented to time and place, or time..." Continued review revealed the patient's Glasgow Coma Scale (scale used to determine the level of consciousness) was 14 indication the patient was alert but confused.

Medical record review of a Patient In Triage (PIT) Screening dated 3/21/17 at 4:33 PM revealed "...patient came from jail, was there for public intoxication. Patient is altered and unable to answer my questions. He talks about being in a car accident but apparently happened a long time ago...[questionable] head injury. He is tangential [lack of focus] in thought processes..."

Medical record review of an ED Physicians assessment dated [DATE] at 5:26 PM revealed "...[AGE] year old male with PMH [past medical history] including Bipolar Disorder, who presents to ED via EMS [emergency medical services] from prison for the evaluation of a head injury that occurred yesterday evening. Patient states he fell last night in his trailer and is unsure how long he was unconscious. Patient is not complaining of head pain on assessment...is very rambling in nature..." Further review revealed "...neurological: alert, oriented to time, place and situation. No focal neurological deficit observed...Psychiatric: manic, flight of ideas, delusional..."

Medical record review of an ED Physicians Reexamination/reevaluation note dated 3/21/17 at 6:19 PM revealed "...patient is highly manic on assessment and is considered a danger to himself and others...I believe the patient merits a psychiatric evaluation...will be held here until one can be obtained..."

Medical record review of a Certificate of Need (CON) for Emergency Involuntary admitted d 3/21/17 at 11:00 PM revealed the patient was to be committed to an inpatient psychiatric facility for delusional and manic behaviors.

Medical record review of an ED Physician's Reexamination/reevaluation note dated 3/21/17 at 4:06 PM revealed "...Pt has paranoid delusions...awaiting placement [inpatient psychiatric]..."

Medical record review of a Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting dated 3/22/17 at 10:30 AM revealed a behavioral assessment was completed on the patient. Further review revealed the patient scored a "...2 [high risk]...risk of danger to self or others and/or severe behavioral disturbance..." Further review revealed "...reported: uncooperative, distorted perception of reality, words or behavior reflect high risk of elopement...psychotic symptoms, hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior..." Further review revealed "...interventions: continuous visual surveillance...observation at all times by designated staff with direct line of sight; must be able to respond to patient rapidly..."

Medical record review of a Psychiatric Consult note dated 3/22/17 at 5:37 PM revealed "...today [Patient #1] is hyperverbal, with flight of ideas, grandiose, and telling staff of big ideas, owns the whole southeast. Doesn't know why he is here...Received Geodon [antipsychotic medication] 10 mg [milligrams] at 4:00 PM today...difficult to evaluate as patient is uncooperative and agitated with threatening demeanor and refuses to answer direct questions but also may not be able to organize thoughts enough to respond. Seems very manic...assessment/plan: bipolar affective disorder-manic...alcohol use disorder...agree with CON...[Patient #1] is unstable, labile and agitated...will follow up if still here..."

Medical record review of an ED Physicians Reexamination/reevaluation note dated 3/22/17 at 6:31 PM revealed "...pt. is widely manic and sexually inappropriate...will continue to be monitored while awaiting placement...flight risk..."

Medical record review of an ED Patient Status Rounding note dated 3/23/17 at 2:40 AM revealed "...All belongings including jacket, hat, shirt, and yellow lighter placed in belongings bag and placed at nurse's station...pt. not obeying verbal commands..."

Review of a facility Event Report dated 3/23/17 at 3:32 AM revealed "...At 3:36 AM fire alarm and sprinkler triggered in room 32 and [named sitter] responded to room and removed the pt. [Patient #1] from fire on bed, removed pt. from room and then returned to room 32 with fire extinguisher...All patients and remaining staff removed from area per policy. [Charge Nurse] along with [Registered Nurse], and [sitter] relocated patients to safe appropriate areas and head count performed on all psychiatric patient and staff removed from affected area. Placed patient [Patient #1] who set fire in room 24 and complete exam was performed on him by [ED Physician] and Respiratory. Patient was then placed in seclusion room...at 3:45 AM..."

Medical record review of an ED Physicians Reexamination/reevaluation note dated 3/23/17 at 4:00 AM revealed "...pt. set his bed on fire in the room and the sprinklers were set off. He denies setting the mattress on fire. Pt. has flight of ideas...denies setting bed on fire. No nasal or facial singing. Oral pharynx clear. Lungs clear no wheezing or rhonchi noted. CXR [chest x-ray] for possible smoke inhalation..."

Interview with the Chief Quality Officer (CQO) on 4/4/16 at 11:30 AM, in the conference room, revealed the patient was confused on admission but did not exhibit behavioral issues until later in the evening. Further interview revealed "...the patient was placed on one to one observation after his behavioral issues worsened...he was on one to one when the incident occurred...he was moved from one room to another room around 11:30 PM...the staff did find a lighter in the patient's belongings which was removed and secured in another room...he had sweat pants and gym shorts on...he apparently had another lighter in his shorts and lit the bed linen with the lighter causing a fire which set off the fire alarm and the sprinkler system in the room..."

Interview with Security Officer #1 on 4/5/17 at 7:30 AM, in the conference room, revealed the officer was the assigned sitter for the patient on 3/23/17. Further interview revealed "...he had pajama bottoms on and underneath them was a pair of black shorts...I was sitting at the nurses desk which is directly across from the room...I saw a spark come from the room and a pop. I immediately went to the room and opened the door...the stretcher and the linen was on fire...the fire alarm then went off and the sprinkler system activated in the room...I immediately got the patient out of the room and took him to another room then returned to the room with the fire extinguisher and sprayed the fire...it was immediately extinguished...the patient was not injured at all...we got all of the patients out of the area and made sure all of the patients were accounted for...the patient [Patient #1] was wet from the sprinkler and had soot on his entire body..."

Interview with Security Officer #2 on 4/5/17 at 8:10 AM, in the conference room, revealed the officer was called on 3/22/17 [previous day] for standby while the patient was relocated...I did not search the patient...he was wearing pajama pants and had gym shorts underneath the pajama pants..."

Interview with Registered Nurse (RN) #1 on 4/5/17 at 8:30 AM, in the conference room, revealed "...he was hypermania, a germophobe, and drug seeking tendencies...he had received Ativan [medication used to treat anxiety] and Geodon [antipsychotic medication] while in the ED and the medications seemed to calm him down..." Further interview revealed "...we moved the patient from room 28 to room 32...he had trashed his room and we wanted to clean the room...the patient had pajama pants on with black gym shorts underneath the pajamas...when we moved him the nursing staff had noticed the patient had clothes in the room and when they searched his room they found a lighter in the room which was confiscated and locked up..." Further interview revealed "...the patient had a sitter...the door was closed...I had stepped into the bathroom and then I heard the fire alarm go off...when I rounded the corner I saw smoke and then saw what was going on...the sitter had already removed the patient from the room and used a fire extinguisher to put the fire out...the sprinkler system had activated and there was water in the room...I did a quick look at the patient [Patient #1] and there did not appear to be any burns or injuries to the patient...the respiratory therapist looked at the patient also...I got [ED Physician] to come and examine the patient...after the fire, security found another lighter in the room that the patient had in his gym shorts..."

Interview with RN #2 on 4/5/17 at 8:45 AM, in the conference room, revealed "...was making rounds and I saw the patient in room 28...he had received meals and drinks and his room was very dirty so we decided to move him to the room 32 so we could get housekeeping to clean the room...in the room we saw a jacket, shoes, pants, and in the pants pocket was a lighter...we placed all of the items in a bag, put his name on the bag and the bag was taken to the nurses station and locked up...about 30 minutes later the fire alarm went off and I heard the overhead page for a Code Red [fire]...the patient had started a fire in room 32...I saw the patient...he had black soot on him and he was wet from the sprinkler system...there was a smell of smoke around him...[ED physician] did an examination on the patient and there were no injuries to the patient, other patients, or the staff..."

Interview with ED Physician #1 on 4/5/17 at 9:15 AM, in the conference room, revealed the physician provided care to the patient while in the ED. Further interview revealed "...the patient did have psychiatric issues...Mobile Crisis Team [team who assists patients who are experiencing mental health emergencies] and psychiatry had seen him in the ED and were trying to get the patient admitted ...the morning of the incident I was in another patient's room. I heard the alarm go off and the overhead page...said the fire was in the ED...when I came out of the room the staff told me the patient had caused a fire and asked me to evaluate the patient...I went to the patient's room...he had black soot all over him and he was wet...I did an examination on the patient and there were no injuries to the patient...he was placed in the seclusion room and monitored..."

Interview with the ED Director on 4/5/17 at 10:30 AM, in the conference room, revealed "...he had gray sweat pants with black shorts underneath...he did not appear to be any threat to himself or others..." Further interview confirmed neither the patient nor his clothing had been thoroughly searched and the patient was able to start a fire with a lighter he had in his clothing.

Interview with the ED Director on 4/18/17 at 11:30 AM, in the CQO office, confirmed the sitter was at the nurses station and the door to patient's room was closed. Further interview confirmed the sitter did not have a direct line of sight to the patient and the patient was not under continuous observation. Continued interview confirmed the facility failed to provide care in a safe setting.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to provide adequate nursing supervision for 2 patients (#1 and #8) of 8 patients reviewed for restraints/seclusion.

The findings included:

During the survey it was found Patient #1 presented to the Emergency Department (ED) on 3/21/17 after a fall. Further review revealed the patient had a psychiatric evaluation performed while in the ED resulting in an involuntary inpatient commitment due to delusional and manic behaviors. Continued review revealed the patient had a history of Bipolar Disease and Alcohol Abuse. On 3/23/17 the ED staff found a lighter in the patient's belongings, which was removed by the staff and the patient was placed under one on one (1:1) observation with a security guard/sitter. Further review revealed the patient had another lighter, not found by the staff, under his gym shorts and the patient used the lighter to start a fire in his room on 3/23/17 at 3:36 AM.

During a conference on 4/18/17 at 10:50 AM, in the Chief Quality Office, with the Chief of Quality Officer and the Administrator, the facility was informed of an Immediate Jeopardy (a situation in which the providers noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment, or death) at CFR PART 482.23 (condition).

Review of a Departmental Memo sent from the Nurse Manager to the ED Staff and Security dated 3/23/17 revealed "...the following will go into effect immediately:
1. Security is to be notified upon arrival of all behavioral health patients. The patient and all belongings will be searched by staff and security.
2. Security will use a metal detector wand in efforts to remove any objects from the patient that could cause harm to self or others. Patient searches will be documented in the patient's medical record and security report.
3. Patients will be asked to empty contents from all pockets.
4. The patient's nurse or team leader will ask the patient for permission to "pat down" their exterior after being scanned with the wand.
5. Patient's possessions will be searched and any high risk items such as sharps, lighters, high heels, will be inventoried, bagged and tagged and locked in the cabinet in the equipment room; this will be documented in the medical record.
6. All behavioral health patients will be searched by staff and security upon presentation, at each shift change, and after visitation.
7. Behavioral health patients will be placed in a gown when placed in seclusion or as indicated based on assessment of patient risk. At that time all items will be removed from their person and room.

Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following were implemented:
(1) the facility began conducting an internal review of the incident on the date it occurred (3/23/17) and developed an initial plan.
(2) the facility self-reported the fire incident on 3/24/17 to the State of Tennessee. The Chief Executive Officer (CEO) notified the Chief Nursing Officer (CNO), Chief of Staff, General Medical Staff, Medical Executive Committee, and the Board of Trustees Chairman of the fire incident. Hospital managers were notified at the hospital on [DATE] during a safety huddle. The Chief Quality Officer (CQO) notified the Quality Improvement Committee.

Immediate Action Plan
The CEO, CNO, CQO, RM (Risk Manager), ED Director, and the Security Director determined there was a need for an enhanced plan for patients identified as being at risk for suicide or behavioral health issues.
ACTION (1) an analysis was completed on the date of the occurrence and indicated changes in policy were needed.

Staff Education
The CEO, CNO, CQO, RM, ED Director, and the Security Director determined staff should receive immediate education on the policy and memo. Education begun on 3/23/17 and is ongoing. In addition, the ED Director and the Security Director educated staff present on 4/18/17 on the policy as well as an example of flow sheets. In addition, all staff involved with suicidal or behavioral health patients will receive education by 4/30/17 via a Power Point. The Power Point education will begin immediately (4/18/17). Directors will ensure education is completed via logging completed tests on the employee roster(s). In addition, staff who have been off will report to their supervisor or the Associate Director of Nursing Services (ADNS) upon returning to work and will be provided the education and test via a handout copy that must be completed and given back to their manager before starting their shift. ADNS will receive their training beginning 4/18/17 and will follow the above process if they have been.

Physician and Allied Health Education
Physicians were educated on the event and policy at the general staff meeting on 4/11/17. This will also occur at the 4/20/17 Medical Executive Meeting.

Board Education
The board will be educated on the policy and the event on April 15, 2017.

Review of a Power Point Presentation dated 4/18/17 revealed the following topics were presented for staff education:
1. Acuity Level Explanations and Interventions regarding the supervision and monitoring of Suicide and Behavioral Health patients.
2. Suicide and Behavioral Disorder Assessment.
3. General Safety "...Interventions...clinical status and patient safety documented every 15 minutes for acuity 1, 2, 3 patients; ensure a safe environment: complete Psych-Safe room checklist...remove all personal belongings from the room and secure...search belongings brought in by visitors for any harmful items..."
4. Review of the required documentation for Suicide or Behavioral Health patients.
Further review revealed upon completion of the Power Point presentation, a post-test completion was required for all staff.

Review of an Educational Attendance Record dated 4/18/17 revealed the security officers and maintenance staff were given education regarding the "Search of Behavioral Health Patients in the ED."

Review of an Educational Presentation "Behavioral Health Observation Education" dated 4/2017, revealed ED staff were given education regarding the following topics:
(1) Documentation (behavorial health observation sheets) is to be completed on paper forms
(2) Patients should receive a "...complete assessment by the primary RN [Registered Nurse] every shift and as needed according to behaviors. Assessments can only be completed by an RN...should be completed at the beginning of the nurse's shift and could coincide with the search and wanding...assessment should be documented on paper but also noted in the chart..."
(3). Documentation will be done as specified:
A. Continuous 1:1 patient to observer
1.Patient is to be continiously monitored but documentation of assessments need to be made every 15 minutes by hospital staff who have completed competency.
2. RN to document assessment every hour on Patient Observation Form.
B. Continuous Visual Surveillance:
1.Ratio may be more than 1:1 but patient is under direct visual observation
2. Observer must be able to attend immediate needs of patient without risking surveillance of the other.
3. Documentation every 15 minutes by hospital staff who have completed competency.
4.RN to document assessment every hour on Patient Observation Form.
C. Close Observation
1.Patient may not be left alone without support person (can be reliable family or friend)
2.Observation is required by hospital staff at a minimum of every 15 minutes.
3.Documentation every 15 minutes by hospital staff who have completed competency.
4.RN to document assessment every hour on RN assessment form.
D. Intermitted Observation:
1.Documentation every 30 minutes by hospital staff with RN documentation.
2.RN to document assessment every hour on Observation Form.
E. Any change from above should be accompanied by an order/suicide risk behavior disorder assessment signed by the physician PRIOR to the change.
1.Take form to the appropriate physician but do not leave it with the physician.
2.Have the physician to sign immediately and return to the chart.
3. Ensuring all documentation is completed is the responsibility of the RN.
4.If a sitter is present then ensure all documentation is completed accurately.
5.Licensed Practical Nurses (LPN) can be used as sitters but cannot chart assessments.
6.Every hour the RN must document on the Patient Observer Monitoring Checklist and in the Electronic Medical Record (EMR) as a nursing note.
(5) If the patient is placed in seclusion or restraints then a Nursing-Violent/Self Destructive Restraints and or Seclusion flow must be completed by the RN. This will accompany the Patient Observation Form.

Review of an Educational Attendance Record dated 4/18/17 revealed the ED Director initiated training for the ED staff related to Behavioral Health Observations.

Review of the Behavioral Health Plan of Action for the ED dated 4/2017 revealed the following:
(1) ED Director will develop a database to track ED employees for completion of both educational presentations.
(2) 100% real time chart checks will begin by Team Leads on 4/18/17.
(3) 100% chart audits to ensure compliance and understanding of training will begin by Assistant ED Manager on 4/19/17.
(4) Any deviations from standards will be forwarded to and addressed by ED Director.

Review of an Electronic Media (e-mail) dated 4/18/17 at 4:44 PM sent from the Administrator to the Senior Management staff revealed:
(1) All ER Staff and Providers must review the Power Point Presentation and take the test under Education on the website for Suicide Risk Behavioral Disorder Assessment.
(2) Any individuals who will be assigned as sitters (security or clinician) responsible for any of these patients throughout the hospital must also complete the power point presentation and corresponding test.
(3) Employees should print off validation that they have completed the test and submit to their manager.
(4) Managers need to maintain a log of who and when the reviews and tests occurred.
(5) Anyone failing to take the test by April 30, 2017, will be suspended until such time the test is completed.
(6) Additionally any log for 15 minute checks or hourly checks on Behavioral Health or suicide patients MUST be completed in its entirety. This is for everyone's safety. Failure to do so can result in disciplinary action.

Interview with the CQO on 4/18/17 at 12:30 PM, in the CQO's office, revealed the facility had implemented a mandatory Power Point related to Behavior Health patients and training had already started. Further interview revealed "...all employees who serve or may serve in a sitter role will be required to complete the training...all ED staff and security personnel will be required to complete the training prior to sitting with any patient...the ED Director will ensure this compliance on a daily basis..." Further interview revealed "...the administrator will send the required information to all of the Directors...each director has an employee roster and they will be responsible for ensuring all of their employees complete the training within the required time frame...this information will be presented in the Quality meetings, the medical executive meeting, and to the Governing Board..."

During a conference on 4/18/17 at 4:05 PM, in the Chief Quality Office, with the Administrator, the Chief Quality Officer, the Emergency Department (ED) Nurse Manger, and the Assistant Chief Nurse Officer (ACNO) the facility presented an Immediate Action Plan for the Immediate Jeopardy. Review of the Action Plan revealed immediate actions were implemented by the facility. The Immediate Jeopardy was removed on 4/18/17.

Refer to Standard A395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to provide adequate nursing supervision for 2 patients (#1 and #8) who were in seclusion of 8 patient's reviewed for restraints/seclusion.

The findings included:

Review of facility policy "Suicide Risk Assessment and Reassessment for Behavioral Health Services" last revised on 3/27/16 revealed "...all patients have the right to be cared for in a therapeutic environment that will promote accurate identification of patients who are at an increased risk for suicide or self-destructive behaviors..." Further review revealed "...Level 2 [high risk]...staff member assigned to line of sight monitoring/observations..."

Review of the Psychiatric Triage Level 2 Interventions, not dated, revealed "...Interventions...provide safe environment...documentation every 15 minutes..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] at 4:06 PM after a fall. Further review revealed the patient was transferred to a psychiatric facility on 3/24/17.

Medical record review of an Emergency Department (ED) Quick Triage assessment dated [DATE] at 4:17 PM revealed "...pt. [patient] arrested at 1058 [10:58 AM] for public intoxication, c/o [complains of] fall and struck head, then went unresponsive in jail...per police..." Further review revealed "...level of consciousness: alert, cooperative, not oriented to time and place, or time..." Continued review revealed the patient's Glasgow Coma Scale (scale used to determine the level of consciousness) was 14 indication the patient was alert but confused.

Medical record review of a Patient In Triage (PIT) Screening dated 3/21/17 at 4:33 PM revealed "...patient came from jail, was there for public intoxication. Patient is altered and unable to answer my questions. He talks about being in a car accident but apparently happened a long time ago...[questionable] head injury. He is tangential [lack of focus] in thought processes..."

Medical record review of an ED Physicians assessment dated [DATE] at 5:26 PM revealed "...[AGE] year old male with PMH [past medical history] including Bipolar Disorder, who presents to ED via EMS [emergency medical services] from prison for the evaluation of a head injury that occurred yesterday evening. Patient states he fell last night in his trailer and is unsure how long he was unconscious. Patient is not complaining of head pain on assessment...is very rambling in nature..." Further review revealed "...neurological: alert, oriented to time, place and situation. No focal neurological deficit observed...Psychiatric: manic, flight of ideas, delusional..."

Medical record review of an ED Physicians Reexamination/reevaluation dated 3/21/17 at 6:19 PM revealed "...patient is highly manic on assessment and is considered a danger to himself and others...I believe the patient merits a psychiatric evaluation...will be held here [ED] until one can be obtained..."

Medical record review of a Certificate of Need (CON) for Emergency Involuntary admitted d 3/21/17 at 11:00 PM revealed the patient was to be committed to an inpatient psychiatric facility for delusional and manic behaviors.

Medical record review of a Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting dated 3/22/17 at 10:30 AM revealed a behavioral assessment was completed on the patient. Further review revealed the patient scored a "...2 [high risk]....risk of danger to self or others and/or severe behavioral disturbance..." Further review revealed "...reported: uncooperative, distorted perception of reality, words or behavior reflect high risk of elopement...psychotic symptoms, hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior..." Further review revealed "...interventions: continuous visual surveillance...observation at all times by designated staff with direct line of sight; must be able to respond to patient rapidly..."

Medical record review of an ED Physicians Reexamination/reevaluation note dated 3/22/17 at 6:31 PM revealed "...pt. [patient] is widely manic and sexually inappropriate...will continue to be monitored while awaiting placement...flight risk..."

Review of a facility Event Report dated 3/23/17 at 3:32 AM revealed "...at 3:36 AM fire alarm and sprinkler triggered in room 32 and [named sitter] responded to room and removed the pt. from fire on bed, removed pt. from room and then returned to room 32 with fire extinguisher...placed patient who set fire in room 24 and complete exam was performed on him by [ED Physician] and Respiratory. Patient was then placed in seclusion room...at 3:45 AM..."

Interview with the Chief Quality Officer (CQO) on 4/4/16 at 11:30 AM, in the conference room, revealed "...the patient was placed on one to one observation after his behavioral issues worsened...he was on one to one on 3/23/17 when the incident occurred...he was moved from one room to another room around 11:30 PM...the staff did find a lighter in the patient's belongings which was removed and secured in another room...he had sweat pants and gym shorts on...he apparently had another lighter in his shorts and lit the bed linen with the lighter causing a fire which set off the fire alarm and the sprinkler system in the room..."

Interview with Security Officer #1 on 4/5/17 at 7:30 AM, in the conference room, revealed the officer was the assigned sitter for the patient on 3/23/17. Further interview revealed "he had pajama bottoms on and underneath them was a pair of black shorts...I was sitting at the nurses desk which is directly across from the room...the door was closed...I saw a spark come from the room and a pop. I immediately went to the room and opened the door...the stretcher and the linen was on fire...the fire alarm then went off and the sprinkler system activated in the room...I immediately got the patient out of the room and took him to another room then returned to the room with the fire extinguisher and sprayed the fire...it was immediately extinguished..."

Interview with Registered Nurse (RN) #1 on 4/5/17 at 8:30 AM, in the conference room, revealed "...there was an assigned sitter...the door was closed...I had stepped into the bathroom and then I heard the fire alarm go off...when I rounded the corner I saw smoke and then saw what was going on...the sitter had already removed the patient from the room and used a fire extinguisher to put the fire out...the sprinkler system had activated and there was water in the room...I did a quick look at the patient [Patient #1] and there did not appear to be any burns or injuries to the patient...I got [ED Physician] to come and examine the patient...after the fire, security found another lighter in the room that the patient had in his gym shorts..."

Interview with RN #2 on 4/5/17 at 8:45 AM, in the conference room, revealed "...was making rounds and I saw the patient in room 28...he had a sitter assigned to him...we decided to move him to the room 32 so we could get housekeeping to clean the room...in the room we saw a jacket, shoes, pants, and in the pants pocket was a lighter...we placed all of the items in a bag, put his name on the bag and the bag was taken to the nurses station and locked up...about 30 minutes later the fire alarm went off and I heard the overhead page for a Code Red [fire]...the patient had started a fire in room 32...I saw the patient...he had black soot on him and he was wet from the sprinkler system...there was a smell of smoke around him...[ED physician] did an examination on the patient and there were no injuries to the patient, other patients, or the staff..."

Interview with the ED Director on 4/5/17 at 10:30 AM, in the conference room, revealed "...he had gray sweat pants with black shorts underneath...he did not appear to be any threat to himself or others..." Further interview revealed the patient had an assigned sitter and the nurses do check on the patients also..."

Interview with the ED Director on 4/18/17 at 11:30 AM, in the CQO office, confirmed the sitter was at the nurse's station and the door to the patient's room was closed. Further interview confirmed the sitter did not have a direct line of sight to the patient and nursing failed to supervise the care of the patient.

Medical record review revealed Patient #8 was admitted the ED on 4/18/17 at 12:30 AM for a Psychiatric Assessment.

Medical record review of a Suicide/Behavior Disorder Assessment for the Non-Behavioral Health Setting dated 4/18/17 at 12:30 AM revealed the patient was assessed as an Acuity Level 2/3, indicating the patient had distorted perception of reality, had psychotic symptoms and the presence of mood disturbances. Continued review revealed the patient was to be observed by nursing every 15 minutes.

Medical record review of Patient Observation Monitoring Checklist dated 4/18/17 revealed no documentation of the 15 minute checks from 7:30 AM until 9:30 AM (2 hours).

Interview with RN #3 on 4/18/17 at 10:30 AM, in the ED Nurses Station, revealed "...the patient presented for a mental health evaluation...she is on every 15 minute checks at this time..." Further interview confirmed the 15 minute checks had not been done between 7:30 AM and 9:30 AM.

Interview with the ED Director on 4/18/17 at 11:30 AM, in the CQO office, confirmed the facility failed to do the 15 minute checks and failed to follow facility policy.