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.

EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY 40511 Oct. 5, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, it was determined the facility failed to ensure the delivery of nursing services to one (1) of thirteen (13) sampled patients (Patient #1). Patient #1 was admitted to the facility on [DATE] exhibiting self-harming behaviors such as attempts to eat non-nutritional items. On 09/05/12 Patient #1 ingested a AA battery while on one to one supervision. On 09/11/12, while being supervised by two (2) Mental Health Associates (MHAs), Patient #1 was on the toilet when staff heard the sound of metal hitting the floor, and saw two washers and a small screw fall to the floor from the toilet. The MHAs were able to get the washers, but weren't quick enough to prevent Patient #1 from consuming the screw. On 09/18/12 Resident#1 ingested two AA batteries, one at 2:30 PM and another at 6:45 PM. The failure of the facility to provide appropriate supervision placed residents at risk for serious injury, harm, impairment or death. The facility was notified on 10/03/12 that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions on 10/03/12. It was determined the Jeopardy was abated on 10/04/12, prior to the survey exit on 10/05/12. (Refer to A0395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and review of the facility's Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, it was determined the facility failed to supervise and evaluate the nursing care to ensure patients at risk for self-harm were properly and adequately supervised for one (1) of thirteen (13) sampled patients (Patients #1).

The facility failed to ensure staff was trained to provide adequate supervision to Patient #1, who was identified exhibiting multiple attempts at Pica (the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age for which this behavior is developmentally inappropriate) from his/her previous placement. Patient #1 was placed on one (1) on one (1) supervision upon admission. Patient #1's Nursing Cardex, dated 08/28/12 and updated as needed, identified atempting to eat non-food items as a concern for staff to be aware of. The Nursing Cardex was reviewed by nursing staff and Mental Health Associates (MHAs) prior to each shift. Despite this information, Patient #1 ingested a AA battery on 09/05/12. Patient #1's Personal Recovery Plan was updated with the need to keep small objects away from Patient #1, and a second MHA was assigned at that time. On 09/11/12, while being supervised by two (2) Mental Health Associates (MHAs), Patient #1 was on the toilet when staff heard the sound of metal hitting the floor, and saw two washers and a small screw fall to the floor from the toilet. The MHAs were able to get the washers, but weren't quick enough to prevent Patient #1 from consuming the screw. Patient #1 was transferred to the Intensive Services Unit (ISU) on 09/13/12, at which time one (1) staff was assigned to provide one (1) on one (1) supervision. Patient #1 was able to ingest a second and third battery on 09/18/12 at 2:30 PM and 6:45 PM, respectively.

The findings include:

A review of the General Hospital Policies, Section 3, Risk Management and Safety Policies, undated, revealed one to one observation was defined as having a patient in clear view and within legs length. The policy describes one on one observation as an option when a patient it high risk due to identified risk factors.

Review of Patient #1's facility admission paperwork revealed Patient #1 was admitted to the facility on [DATE] with diagnoses which included Impulse Control Disorder NOS and exhibiting self-harming behaviors such as attempts to eat non-nutritional items. A Monthly Psychiatric Statement from Patient #1's previous placement identified multiple atempts of PICA resulting in emergency room (ER) visits, further citing incidents in which Patient #1 had inhaled a co-axial cable into his/her lung, drank a corrosive fluid that burned his/her esophagus, and frequent attempts at eating rocks.

An interview with Mental Health Associate (MHA) #3, on 09/27/12 at 3:35 PM, and review of Patient #1 Personal Recovery Plan upon admission revealed Patient #1 was placed on 1:1 supervision upon his/her admission to the facility on [DATE].

Review of the Shift Assessment Daily Notes, dated 09/05/12, revealed at 3:50 PM Patient #1 swallowed a AA battery. X-rays were ordered and staff were to monitor Patient #1's stool for passage of the battery.

In an interview on 09/27/12 at 3:35 PM, MHA #3 revealed Patient #1 was given headphones on 09/05/12 with MHA #3 providing supervision. He stated Patient #1 was adjusting the headphones when two (2) AA batteries fell out onto Patient #1's bed. MHA #3 stated both he and Patient #1 reached for the batteries, with each getting one (1) battery. MHA #3 stated Patient #1 inserted his/her battery into the headphones then held his/her hand out for the second battery. MHA #3 stated he gave Patient #1 the second AA battery, but instead of placing the battery back in the headphones, Patient #1 consumed the battery before he could prevent it. MHA #3 went on to reveal the incident was reported, and x-rays conducted a day or two later confirmed the battery had passed through Patient #1. MHA #3 state he was within arms length of Patient #1 the entire time.

Review of Patient #1's Personal Recovery Plan revealed a Review Note stating Patient #1 had consumed a AA battery, and also that he/she had a history of eating non-nutritional items. Further, two (2) staff were assigned to Patient #1 at all times due to his/her behavioral issues. Two staff remained assigned to Patient #1 until his/her placement on ISU on 09/13/12.

An interview with Registered Nurse (RN) #4, on 09/26/12 at 1:41 PM, revealed on 09/11/12 the MHAs supervising Patient #1 while Patient #1 was on the toilet heard the sound of metal hitting the floor, and saw two washers and a small screw fall to the floor from the toilet. RN #4 revealed MHAs were able to get the washers, but weren't quick enough to prevent Patient #1 from consuming the screw. RN #4 revealed Patient #1 was transferred to the facility's Intensive Service Unit (ISU) on 09/13/12 for a less stimulating and more easily controlled environment.

An interview with MHA #2, on 09/26/12 at 2:53 PM, revealed he was providing 1:1 supervision to Patient #1 on 09/18/12. MHA #2 revealed he had prevented Patient #1 from consuming styrofoam cups and toilet paper during previous assignments to supervise Patient #1. MHA #2 stated he escorted Patient #1 to a conference room on another unit on 09/18/12 at 2:30 PM to meet with a social worker from adult protective services. MHA #2 stated he held the door for the social worker and Patient #1 to enter, then entered and sat down opposite the social worker. MHA #2 went on to state that after about a minute and a half of conversation between Patient #1 and the social worker, Patient #1 reached out to the middle of the table where he/she had noticed a AA battery and consumed it before he [MHA #2] could react. MHA #2 stated he had not noticed the battery on the table, as his view was obscured by books and papers.

An interview with RN #5, on 09/26/12 at 3:40 PM, revealed she was the nurse assigned to ISU on the evening of 09/18/12. She revealed she had received report about the incident from earlier in the day in which Patient #1 had consumed a AA battery. RN #5 stated Patient #1 was acting out "more than usual" that evening, and she had asked Patient #1 what would calm him/her down, to which Patient #1 responded "music." RN #5 stated she gave headphones to MHA #4 in an effort to calm Patient #1. RN #5 stated neither she nor the MHAs on the unit were thinking about batteries, instead concentrating their efforts on calming Patient #1. She revealed Patient #1 did listen to music for a short time, but she was informed about four minutes after providing the headphones at approximately 6:40 PM that he/she had ate a battery. RN #5 stated that she made an error in judgement, and had been verbally re-educated by supervisory staff.

Interview with MHA #4, on 09/27/12 at 3:35 PM, revealed he was assigned to Patient #1 on 09/18/12 and was in the room supervising along with another MHA when Patient #1 consumed a AA battery. MHA #4 stated he reached into Patient #1's mouth in an effort to prevent the incident, but stated Patient #1 was too fast.

An interview with RN #3, Nurse Manager for the ISU, on 10/02/12 at 9:00 AM, revealed the importance of ensuring non-patient areas are cleared out for safety prior to taking a resident into a non-patient area was stressed during morning meeting to all nurse managers. In a second meeting later that day at 11:32 AM, RN #3 stated this was stressed again in morning meeting on 09/24/12, and nurse managers passed this on to their staff on that date and the following date.

An interview with the Director of Nursing (DON), on 10/03/12 at 11:45 AM, revealed Patient #1 had no history of consuming batteries prior to the current admission. The DON went on to reveal Patient #1 had previous admissions and music had been used effectively to calm Patient #1. The DON revealed program managers were to ensure the environment was safe for patients prior to meetings with patients. On 09/18/12 the meeting was not planned, and program managers were not aware of the need to ensure the conference room was safe for patients.

A review of a Document Review Report revealed Patient #1 was admitted to a local hospital on [DATE] at 11:42 PM for a colonic ulcer secondary to accidental ingestion of battery. The facility sent Patient #1 to the hospital due to a blood pressure in the 50s, Patient #1 collapsing while attempting to stand, and having a loose dark red bowel movement. The report revealed Patient #1's hemoglobin was 7.1 on admission, and an abdominal x-ray showed a AA battery in the gastric antrum. The hospital endoscopically removed the AA battery and transfused four (4) units of blood. Patient #1 was returned to the facility on [DATE].

An interview, on 10/04/12 at 9:00 AM, with the Risk Manager revealed staff had been working hard to ensure all staff were knowledgeable and competent in ensuring non-patient areas were safe prior to taking a patient into said areas. The Risk Manager revealed second and third shift staff had been educated on 10/03/12, and first shift staff had been educated on 10/04/12. Further, the Risk Manager revealed employees would receive the education and verbal competency test prior to returning to work.

A review of an e-mail sent to facility supervisory staff from the Nursing Services Coordinator on 10/03/12 revealed staff were to be tested for competency with the question "What items might you remove from a non-patient areas prior to a meeting that involves a patient?", allowing staff to sign that they had the training only when they were able to provide correct answers. A review of the training document Patient Safety/Non-Patient Area defined non-patient areas and also items that could be potentially dangerous. Additionally, the Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, undated, was reviewed along with the training document. In-Service Training Report Forms with employee signatures were obtained for all shifts.

An interview with MHA #12, on 10/04/12 at 9:51 AM, revealed he had received training prior to coming on shift on 10/03/12 at 6:00 PM. He was able to provide examples of items to remove from a room for agressive and self-harming behaviors, including Pica.

This was further verified in an interview with MHA #13, on 10/04/12 at 10:15 AM, who worked 6:00 PM to 7:30 AM on 10/03/12. She stated a nurse reviewed with her the sharps policy and patient safety in non-patient areas. MHA #13 revealed she had been questioned by the nurse, and was not allowed to sign for the training or begin her work until she was able to answer the questions asked.

An interview with MHA #18, on 10/04/12 at 11:15 AM, revealed she received the inservice that morning. MHA #18 revealed she would have someone take over her one on one observation of a patient until she was able to ensure the environment was safe for the patient to enter.

The facility failed to ensure patients at risk for self-harm were properly and adequately supervised. This failure placed patients at risk for injury, harm, impairment or death. On 09/18/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions. Those actions were as follows: The facility retrained staff on their Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, which stated "staff must always supervise patients and ensure they are in a safe and secure environment." The facility developed a Patient Safety/Non-Patient Area training emphasizing supervision and safety of patients, and identifying both dangerous items and non-patient areas. The facility tested staff prior to their return to work on what they would do to ensure a non-patient area was made safe for patients prior to utilizing the area; staff were not allowed to return to work until verbally demonstrating competency in ensuring non-patient areas were made safe for patients. Staff who were not working were to be educated and tested prior to their return to work.

The Immediate Jeopardy was determined to be abated on 10/04/12, prior to the exit of the survey.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and review of facility's policies, it was determined the facility failed to provide one (1) of thirteen (13) sampled patients (Patient #1) care in a safe setting (see A0144) and supervision by trained staff (see A0175). Resident #1 was admitted to the facility on [DATE] with a known history of exhibiting self-harming behaviors such as attempts to eat non-nutritional items. On 09/05/12, despite historically being able to use headphones without incident, Resident #1 ingested a AA battery from a set of headphones. On 09/11/12, while being supervised by two (2) Mental Health Associates (MHAs), Patient #1 was on the toilet when staff heard the sound of metal hitting the floor, and saw two washers and a small screw fall to the floor from the toilet. The MHAs were able to get the washers, but weren't quick enough to prevent Patient #1 from consuming the screw. On 09/18/12 Resident#1 ingested two AA batteries, one at 2:30 PM and another at 6:45 PM. The failure of the facility to provide a safe environment and appropriate supervision placed residents at risk for serious injury, harm, impairment or death. The facility was notified on 10/03/12 that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 10/04/12, prior to the exit on 10/05/12. (Refer to A0144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of the facility's Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, it was determined the facility failed to ensure patients at risk for self-harm were properly and adequately supervised for one (1) of thirteen (13) sampled patients (Patients #1).

The facility failed to ensure staff was trained to provide adequate supervision to Patient #1, who was identified exhibiting multiple attempts at Pica (the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age for which this behavior is developmentally inappropriate) from his/her previous placement. Patient #1 was placed on one (1) on one (1) supervision upon admission. Patient #1's Nursing Cardex, dated 08/28/12 and updated as needed, identified atempting to eat non-food items as a concern for staff to be aware of. The Nursing Cardex was reviewed by nursing staff and Mental Health Associates (MHAs) prior to each shift. Despite this information, Patient #1 ingested a AA battery on 09/05/12. Patient #1's Personal Recovery Plan was updated with the need to keep small objects away from Patient #1, and a second MHA was assigned at that time. Patient #1 was transferred to the Intensive Services Unit (ISU) on 09/13/12, at which time one (1) staff was assigned to provide one (1) on one (1) supervision. Patient #1 was able to ingest a second and third battery on 09/18/12 at 2:30 PM and 6:45 PM, respectively.

The findings include:

A review of the General Hospital Policies, Section 3, Risk Management and Safety Policies, undated, revealed one to one observation is defined as having a patient in clear view and within legs length. The policy describes one on one observation as an option when a patient was a high risk due to identified risk factors.

Review of Patient #1's facility admission paperwork revealed Patient #1 was admitted to the facility on [DATE] with diagnoses which included Impulse Control Disorder NOS and exhibiting self-harming behaviors such as attempts to eat non-nutritional items. A Monthly Psychiatric Statement from Patient #1's previous placement identified multiple atempts of Pica resulting in emergency room (ER) visits, further citing incidents in which Patient #1 had inhaled a co-axial cable into his/her lung, drank a corrosive fluid that burned his/her esophagus, and frequent attempts at eating rocks.

Review of the Shift Assessment Daily Notes, dated 09/05/12 revealed at 3:50 PM Patient #1 swallowed a AA battery. X-rays were ordered and staff was to monitor Patient #1's stool for passage of the battery.

Mental Health Associate (MHA) #3, in an interview on 09/27/12 at 3:35 PM, revealed Patient #1 was given headphones on 09/05/12 with MHA #3 providing supervision. He stated Patient #1 was adjusting the headphones when two (2) AA batteries fell out onto Patient #1's bed. MHA #3 stated both he and Patient #1 reached for the batteries, with each getting one (1) battery. MHA #3 stated Patient #1 inserted his/her battery into the headphones then held his/her hand out for the second battery. MHA #3 stated he gave Patient #1 the second AA battery, but instead of placing the battery back in the headphones, Patient #1 consumed the battery before he could prevent it. MHA #3 went on to reveal the incident was reported, and x-rays conducted a day or two later confirmed the battery had passed through Patient #1. MHA #3 stated he was within arms length of Patient #1 the entire time.

Review of Patient #1's Personal Recovery Plan, dated 09/06/12, revealed a Review Note stating Patient #1 had consumed a AA battery, and also that he/she had a history of eating non-nutritional items. Further, two (2) staff were assigned to Patient #1 at all times due to his/her behavioral issues and two (2) staff remained assigned to Patient #1 until his/her placement on the Intensive Service Unit (ISU) on 09/13/12.

An interview with Registered Nurse (RN) #4, on 09/26/12 at 1:41 PM, revealed on 09/11/12 the two (2) MHAs supervising Patient #1 while Patient #1 was on the toilet heard the sound of metal hitting the floor, and saw two washers and a small screw fall to the floor from the toilet. RN #4 revealed MHAs were able to get the washers, but weren't quick enough to prevent Patient #1 from consuming the screw. RN #4 revealed Patient #1 was transferred to the facility's ISU on 09/13/12 for a less stimulating and a more controlled environment.

Review of Patient #1's Personal Recovery Plan revealed it was not updated following this incident, nor was more staff assigned to the supervision of Patient #1.

An interview with MHA #2 on 09/26/12 at 2:53 PM revealed he was providing one (1) on one (1) supervision to Patient #1 on 09/18/12, which he had been trained on in orientation. MHA #2 revealed Patient #1's supervision had been made one on one since placement on ISU. MHA #2 revealed he had prevented Patient #1 from consuming styrofoam cups and toilet paper during previous assignments to supervise Patient #1. MHA #2 stated he escorted Patient #1 to a conference room on another unit on 09/18/12 at 2:30 PM to meet with a social worker from adult protective services. MHA #2 stated he held the door for the social worker and Patient #1 to enter, then entered and sat down opposite the social worker. MHA #2 went on to state that after about a minute and a half of conversation between Patient #1 and the social worker, Patient #1 reached out to the middle of the table where he/she had noticed a AA battery and consumed it before he [MHA #2] could react. MHA #2 stated he had not noticed the battery on the table, as his view was obscured by books and papers. MHA #2 stated he did not know for certain who was responsible for ensuring the conference room was safe for Patient #1, although stated he did not notice anything dangerous upon entering.

An interview with RN #5, on 09/26/12 at 3:40 PM, revealed she was the nurse assigned to ISU on the evening of 09/18/12. She revealed she had received report about the incident from earlier in the day in which Patient #1 had consumed a AA battery. RN #5 stated Patient #1 was acting out "more than usual" that evening, and she had asked Patient #1 what would calm him/her down, to which Patient #1 responded "music." RN #5 stated she gave headphones to MHA #4 in an effort to calm Patient #1. RN #5 stated neither she nor the MHAs on the unit were thinking about batteries, instead concentrating their efforts on calming Patient #1. She revealed Patient #1 did listen to music for a short time, but she was informed about four minutes after providing the headphones at approximately 6:40 PM that Patient #1 had eaten a battery. RN #5 stated she made an error in judgement, and had been verbally re-educated by supervisory staff.

Interview with MHA #4, on 09/27/12 at 3:35 PM, revealed he was assigned to Patient #1 on 09/18/12, and was in the room supervising along with another MHA when Patient #1 consumed a AA battery. MHA #4 stated he reached into Patient #1's mouth in an effort to prevent the incident, but stated Patient #1 was too fast.

An interview with RN #3, Nurse Manager for the ISU, on 10/02/12 at 9:00 AM, revealed on 09/19/12 the importance of ensuring non-patient areas were cleared out for safety prior to taking a resident into a non-patient area was stressed during morning meeting to all Nurse Managers. In a second meeting later that day at 11:32 AM, RN #3 stated this was stressed again in morning meeting on 09/24/12, and nurse managers passed this on to their staff on that date and the following date.

An interview with MHA #5, on 09/28/12 at 4:07 PM, revealed he had worked with Patient #1 in the past. MHA #5 defined one (1) on one (1) supervision as keeping one's eyes on the patient and keeping the patient within arms length. MHA #5 further revealed areas were surveyed for small items prior to escorting Patient #1 into the areas, although he was unable to reveal who would be responsible for supervising Patient #1 while areas were being surveyed.

Interview with MHA #8, on 10/02/12 at 9:53 AM, revealed one (1) on one (1) supervision was within arms length, including when patients were in the restroom or sleeping. MHA #8 also revealed he would check a room in advance of letting Patient #1 enter, and was also unable to reveal who would be responsible for supervising Patient #1 while he was checking a room.

Interview with MHA #9, on 10/02/12 at 10:21 AM, revealed one (1) on one (1) was keeping a patient within arms length and sight at all times. Further, MHA #9 revealed a patient on one (1) on one (1) must have their head and hands visible while sleeping. MHA #9 revealed she would ask someone to watch a patient on one (1) on one (1) while she ensured an area was safe, or would ask someone else to ensure an area was safe while she maintained supervision.

An interview with MHA #20, on 10/02/12 at 11:12 AM, revealed she had been educated regarding the importance of ensuring non-patient areas are safe before bringing a patient into those areas, but was unable to identify who would monitor her one on one patient if she were bringing a patient to an unplanned meeting.

A review of a Document Review Report revealed Patient #1 was admitted to a local hospital on [DATE] at 11:42 PM for a colonic ulcer secondary to accidental ingestion of battery. The facility sent Patient #1 to the hospital due to a blood pressure in the 50s, Patient #1 collapsing while attempting to stand, and having a loose dark red bowel movement. The report revealed Patient #1's hemoglobin was 7.1 on admission to the local hospital, and an abdominal x-ray showed a AA battery in the gastric antrum. The hospital endoscopically removed the AA battery and transfused four (4) units of blood. Patient #1 was returned to the facility on [DATE].

An interview with the DON, on 10/03/12 at 11:45 AM, revealed Patient #1 had no history of consuming batteries prior to the current admission. DON went on to reveal Patient #1 had previous admissions and music had been used effectively to calm Patient #1. The DON revealed program managers are to ensure the environment is safe for patients prior to meetings with patients. On 09/18/12 the meeting was not planned, and program managers were not aware of the need to ensure the conference room was safe for patients. Regarding the second incident on 09/18/12, the DON stated staff should've considered headphones to be potentially dangerous as Patient #1's consumption of AA batteries was clearly identified.

An interview, on 10/04/12 at 9:00 AM, with the Risk Manager revealed staff had been working hard to ensure all staff were knowledgeable and competent in ensuring non-patient areas were safe prior to taking a patient into said areas. The Risk Manager revealed second and third shift staff had been educated on 10/03/12, and first shift staff had been educated on 10/04/12. Further, the Risk Manager revealed employees would receive the education and verbal competency test prior to returning to work.

A review of an e-mail sent to facility supervisory staff from the Nursing Services Coordinator on 10/03/12 revealed staff were to be tested for competency with the question "What items might you remove from a non-patient areas prior to a meeting that involves a patient?", allowing staff to sign that they had the training only when they were able to provide correct answers. A review of the training document Patient Safety/Non-Patient Area defined non-patient areas and also items that could be potentially dangerous. Additionally, the Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, undated, was reviewed along with the training document. In-Service Training Report Forms with employee signatures were obtained for all shifts.

An interview with MHA #12, on 10/04/12 at 9:51 AM, revealed he had received training prior to coming on shift on 10/03/12 at 6:00 PM. He was able to provide examples of items to remove from a room for agressive and self-harming behaviors, including Pica.

This was further verified in an interview with MHA #13, on 10/04/12 at 10:15 AM, who worked 6:00 PM to 7:30 AM on 10/03/12. She stated a nurse reviewed with her the sharps policy and patient safety in non-patient areas. MHA #13 revealed she had been questioned by the nurse, and was not allowed to sign for the training or begin her work until she was able to answer the questions asked.

An interview with MHA #18, on 10/04/12 at 11:15 AM, revealed she received the inservice that morning. MHA #18 revealed she would have someone take over her one on one observation of a patient until she was able to ensure the environment was safe for the patient to enter.

The facility failed to ensure patients at risk for self-harm were properly and adequately supervised. This failure placed patients at risk for injury, harm, impairment or death. On 09/18/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions. Those actions were as follows: The facility retrained staff on their Patient Safety: Supervision of Sharps and Potentially Dangerous Items Policy, which stated "staff must always supervise patients and ensure they are in a safe and secure environment." The facility developed a Patient Safety/Non-Patient Area training emphasizing supervision and safety of patients, and identifying both dangerous items and non-patient areas. The facility tested staff prior to their return to work on what they would do to ensure a non-patient area was made safe for patients prior to utilizing the area; staff were not allowed to return to work until verbally demonstrating competency in ensuring non-patient areas were made safe for patients. Staff who were not working were to be educated and tested prior to their return to work.

The Immediate Jeopardy was determined to be abated on 10/04/12, prior to the exit of the survey.