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.

FRIENDS HOSPITAL 4641 ROOSEVELT BOULEVARD PHILADELPHIA, PA 19124 Dec. 14, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility documents, observations, review of facility policies and procedures, review of facility documents, review of medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to ensure compliance with the Patient Rights Condition of Participation (A-0115), failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" prior to discharge (A-0117), failed to provide care in a safe setting (A-0144), failed to ensure that restraint orders contained the type of mechanical restraints (A-0168), failed to ensure patients were allowed visitors of their own choice (A-0215), failed to ensure a Medical Staff Member followed facility Bylaws and policies and procedures and was available for emergency care (A-0353), failed to ensure compliance with the Nursing Services Condition of Participation to ensure accurate and consistent facility policies and procedures were available to Nursing staff and to ensure staff followed established policies and procedures (A-0385), and failed ensure compliance with the Physical Environment Condition of Participation to ensure a safe Physical Environment was provided to all patients that resulted in a suicide death of one patient (A-0700).

Findings include:

Review of facility document "Governing Board Bylaws of Friends Hospital" reviewed June 2016 revealed "Article II General Provisions 2.1 Hospital Management. The Partnership, which owns and operates the business of Hospital, is managed under the direction of the Partnership Board of Managers. The role and purpose of the Hospital is to provide an organization and facility supporting qualified medical professionals in providing quality health care to patients treated in the Hospital ... 2.3 Functions and Duties. The functions and duties of the Governing Board shall be as directed from time to time by the Partnership Board of Managers, consistent with the standards of JACHO (Joint Commission) and of applicable state and federal laws and regulations."


Cross Reference:
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) Patient Rights - Notice of Rights
482.13(e)(5) Patient Rights - Restraint or Seclusion
482.13(h) Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review observations, review of facility policies and procedures, review of facility documents, review of medical records (MR) and interviews with staff (EMP), it was determined the facility failed to ensure the Patients Rights Condition of Participation by failing to provide Patient Notice of Rights (A-0114), by failing to provide care in a safe setting (A-0117),by failing to identify the type of restraints used (A-0168), and by failing to ensure Patient Visitation Rights (A-0215).


Cross Reference:
482.12 -Governing Body
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) -Patient Rights - Notice of Rights
482.13(e)(5) -Patient Rights - Restraint or Seclusion
482.13(h) -Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of policies and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" prior to discharge for four of five medical records reviewed for IMM (MR15, MR16, MR17, and MR18).

Findings include:

Review on November 30, 2016, of policy "Medicare Discharge Appeal Rights", dated July 2014, revealed "II. Policy: ... 3. A second copy of the signed IMM form will be delivered not more than two days before the day of discharge ... 5. The hospital will be able to demonstrate compliance with these requirements with the original signed and dated forms from admission and discharge placed in the chart."

Review on November 30, 2016, of MR15 revealed the patient was admitted to the facility on on [DATE], and discharged on [DATE]. Further review of MR15 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on November 30, 2016, of MR16 revealed the patient was admitted to the facility on on [DATE], and discharged on [DATE]. Further review of MR16 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on November 30, 2016, of MR17 revealed the patient was admitted to the facility on on [DATE], and discharged on [DATE]. Further review of MR17 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on November 30, 2016, of MR18 revealed the patient was admitted to the facility on on [DATE], and discharged on [DATE]. Further review of MR18 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Interview on November 30, 2016, at 1:23 PM, with EMP4 confirmed there was no documented evidence that a a second IMM was given prior to discharge for each patient in MR15, MR16, MR17, and MR18.

Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(e)(5) Patient Rights - Restraint or Seclusion
482.13(h) Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
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 and procedures, review of facility document, review of medical records (MR) and interviews with staff (EMP), it was determined the facility failed to ensure care was provided in a safe setting resulting in a suicide death of one patient and a potential for harm for all patients on suicide precautions (MR1).

Findings include:

Review of facility report dated November 13, 2016, revealed a patient (MR1) was found hanging in their room on November 12, 2016, and was transported to acute care where they were pronounced dead.

Review on November 29, 2016, of MR1 revealed the patient was admitted to the facility on on [DATE], and was transferred to the Emergency Department on November 12, 2016, after staff found the patient hanging with a sheet around the neck from a door hinge in the patient's room.

Review on November 29, 2016, of facility document dated 11/29/16 revealed the facility had 192 patient beds with a patient of census 166, and 75.3% were ordered on Suicide Precautions.

Review on November 29, 2016, of facility document dated January 2015 revealed environmental safety concerns were identified and reported to the Governing Body in May 2015.

Review on November 29, 2016, of Governing Board Meeting Minutes dated May 12, 2015, revealed "The anti-ligature project is progressing on schedule and on budget. 192 bedrooms and bathrooms will be retrofitted. Twenty two patient rooms as well as some of the communal restrooms have been completed thus far."

Review on November 29, 2016, of facility policy and procedures "Environmental Rounds" reviewed November 10, 2015, revealed "Friends Hospital will conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risk."

Review on December 2, 2016, of facility documents "Monthly Safety Inspection Checklist" dated October 2016 revealed the following for eight patient care units:

"Patient Bedrooms and Bathrooms
Unit BN1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit BN2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. Needs [checked].
Unit BS1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. Needs [checked].
Unit TE1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit TE2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit TW1 ... 5. no documentation for patient bedrooms and bathrooms.
Unit TW2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].

Review on November 30, 2016, of facilty document revealed eight patient care units with status of completion of antiligature, piano hinges, door knobs and bed slats to cover loopable holes in bed frames as follows:

BN1 - Older Adult- 24 beds, completed for anti-ligature, piano hinges, knobs, bed slats completed on 23 beds, last bed scheduled for completion 11/30/16.
BS1 Intensive Adult - 26 beds, 24/26 beds completed for anti-ligature, all bed completed for piano hinges, door knobs replacement but still required bed slats for 26 rooms.
BN2- General Adult - 24 beds -all piano hinges completed, 21 rooms required anti-ligature, door knobs replacement and all 24 beds still required bed slats.
BS2- adolescent unit, 24 beds - all rooms completed for anti-ligature, piano hinges, door knobs replacment. All 24 beds required bed slats.
TW1- General Adult - 24 beds - all piano hinges, all 24 beds required anti-ligature, door knobs, bed slats.
TE1 - General Adult - 22 beds- all piano hinges vent were completed, all 22 beds required anti-ligature, door knobs, bed slats.
TW2- General Adult - 24 beds-all required bed slats, the anti-ligature, piano hinges, door knobs were completed.
TE2- General Adult -24 beds- all Piano hinges completed; still required anti-ligature, door knobs and bed slats not completed for all 24 beds.

Interview with EMP1 on November 30, 2016, at 10 AM confirmed the above unit safety replacement status and lack of completion of safety upgrades.

Review on December 2, 2016, of facility document for status update on physical environment status update regarding vent and a/c covers presented to surveyor on December 2, 2016, revealed the following % of completion for Vents and A/C covers for patient care units as follows:

TE2 - Vents completed 100%, 0% A/C covers.
TW2 - completed for vents and A/C covers.
TE1 - 100% vents, 0% A/C covers
TW1 - 100% vents, 0% A/C covers
BS2 - 96% vents and A/C covers
BN2 - 100% vents, A/C covers 13%
BS1 - 92% vents and A/C covers
BN1 - 71% vents and A/C covers

Interview with EMP10 on December 2, 2016, at 2:30 PM confirmed the above completion status of the vent and A/C covers. EMP10 also confirmed the Monthly Unit Inspections rounds were conducted by unit managers.

Interview on November 29, 2016, with EMP1 at 4 PM confirmed the environmental safety concerns were identified in January 2015, presented to the Governing Body in May 2015 and were not yet completed at the beginning of the investigation survey that began on November 29, 2016. Further interview with EMP1 confirmed the death of the patient in MR1 was the result of suicide by hanging with a bed sheet on the door hinge in the patient's room.


Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13(a)(1 -) Patient Rights - Notice of Rights
482.13(e)(5)- Patient Rights - Restraint or Seclusion
482.13(h) -Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that restraint orders contained the type of mechanical restraints for five of five medical records reviewed for mechanical restraints (MR9, MR10, MR11, MR12, and MR13).

Findings include:

Review on November 30, 2016, of facility policy "Restraint/Physical Holds," dated April 2014, revealed " ... Procedure: ... 4. ... b. The physician's orders specify ... the type of restraint ..."

Review of facility document "Restraint/Seclusion," dated April 26, 2016, revealed "Type: [with a check box next to] Mechanical Restraints ..."

Review on November 30, 2016, of MR9 revealed a "Restraint/Seclusion" form, dated October 14, 2016, with a check mark at "Type: ... Mechanical Restraints ..." There was no documentation in the physician order to indicate if the restraint was for a mechanical two point, three point, or four point restraint. Further review of MR9 revealed the patient was placed in restraints. There was no physician documentation to clarify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Review on November 30, 2016, of MR10 revealed a "Restraint/Seclusion" form, dated October 7, 2016, with a check mark at "Type: ... Mechanical Restraints ..." There was no documentation in the physician order to indicate if the restraint was for a mechanical two point, three point, or four point restraint. Further review of MR10 revealed the patient was placed in restraints. There was no physician documentation to clarify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Review on November 30, 2016, of MR11 revealed a "Restraint/Seclusion" form, dated October 4, 2016, with a check mark at "Type: ... Mechanical Restraints ..." There was no documentation in the physician order to indicate if the restraint was for a mechanical two point, three point, or four point restraint. Further review of MR11 revealed the patient was placed in restraints. There was no physician documentation to clarify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Review on November 30, 2016, of MR12 revealed a "Restraint/Seclusion" form, dated October 19, 2016, with a check mark at "Type: ... Mechanical Restraints ..." There was no documentation in the physician order to indicate if the restraint was for a mechanical two point, three point, or four point restraint. Further review of MR12 revealed the patient was placed in restraints. There was no physician documentation to clarify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Review on November 30, 2016, of MR13 revealed a "Restraint/Seclusion" form, dated October 7, 2016, with a check mark at "Type: ... Mechanical Restraints ..." There was no documentation in the physician order to indicate if the restraint was for a mechanical two point, three point, or four point restraint. Further review of MR13 revealed the patient was placed in restraints. There was no physician documentation to clarify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Interview on November 30, 2016, with EMP4, at 12:29 PM, confirmed the physicians orders for MR9, MR10, MR11, MR12, and MR13 "mechanical restraints" do not specify the specific type of mechanical restraints to be used and if the patient was to be placed in two, three, or four point mechanical restraints.

Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) - Patient Rights - Notice of Rights
482.13(h) - Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
Based on facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure patients were allowed visitors of their own choice.

Findings include:

Review on November 29, 2016, of policy "Visitation and Telephone Contacts Guidelines", dated November 2014, revealed "Visitors: ... 3. Visitors between the ages of 16-21 allowed to visit only with an accompanying adult ... 4. Visitors under the age of 16 not allowed on the adult units ... 6. For the adolescent unit, only parents or guardians may visit except for the special written order by physician ... Restriction of Visitors: 1. Patients have the right to receive visitors unless that right is specifically denied by a physician's order."

Review on November 29, 2016, of "Bill of Rights", dated May 2014, revealed "... 2. You have the right to ... including the following rights: ... d. To receive visitors of your own choice ..."

Interview with EMP2, on November 30, 2016, at 2:35 PM, confirmed the above facility policy did not allow patients the visitors of their own choice.

EMP2 further confirmed the restriction did not address why the visitation restrictions were reasonably or clinically necessary.



Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) - Patient Rights - Notice of Rights
482.13(e)(5) -Patient Rights - Restraint or Seclusion
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on review of Medical Staff Bylaws, review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure a medical staff member was available for emergency care, failed to ensure a transfer order was obtained and failed to ensure there was Medical Staff documentation of the emergent event for one of five medical records reviewed (MR1).

Findings include:

Review on December 1, 2016, of facility's "Medical Staff Bylaws" adopted on June 26, 2016, revealed "Article 3 Care and Treatment, Including Orders 3.1 Conduct of Care ... 3.1.3 Each Medical Staff member shall comply with all special treatment policies and protocols adopted by the Hospital, in compliance with applicable law, and all other federal and state requirements governing patient rights and patient care ... 3.2 Orders 3.2.1 All orders for treatment shall be in writing, except that oral orders for medication or treatment shall be accepted only under urgent circumstances ... ".

Review on December 1, 2016, of facility policy and procedures "Medical Emergency Response Procedure (Rapid Response)" revealed " ... III. b. Medical Emergency Activation: i. Hanging/Strangulation/Threatened Airway ... IV. Procedure: a. Responders: i. Physician Response: 1. One physician or physician extender (PA-C or CRNP) to every medical emergency at Friends Hospital ... c. After Medical Emergency is over: i. Physician/PA-C, CRNP in charge of medical emergency will write a progress note about the event."

Review on December 1, 2016, of facility policy "Transfer to emergency room and Return of Individual to the Inpatient Unit" reviewed July 2016 revealed " ... IV. Procedure: 6. The Internist, and in his absence the psychiatrist or Nurse Practitioner, will make the determination regarding transfer to an acute care facility Emergency Department."

Review of nursing documentation for MR1 dated November 12, 2016, timed at 17:30 [5:30 PM]revealed " ... I last saw [patient] at 15:56 [3:56 PM] walking past the nurses station to the laundry room with staff. At 1615 [staff] came to me stating '[patient] hung self.' I called for staff and ran to [patient's] room where I saw [patient] hanging from door top hinge by a sheet tied around neck. Code white and 911 were called. [Patient] was brought down to the floor and CPR was started, AED pads applied no shock advised x 4 EMS arrived continued CPR with AED, pushed IV meds/fluids and intubated. [Patient] then transported to [acute care Emergency Department]."

Review on November 30, 2016, of MR1's "Medical Emergency Evaluation Code" dated 11/12/16 at 16:00 revealed " ... 14. Did a physician arrive? "Yes" column was checked. Time? [not documented]. Further review of the document revealed no documentation of either a written or verbal transfer order to an acute care Emergency Department.

Further review of MR1 on November 30, 2016, revealed no documentation of a Medical Staff written or verbal transfer order for MR1. Continued review of MR1 revealed no documentation of a Medical Staff member progress note for the event on November 12, 2016.

On November 30, 2016, surveyor requested the credential file of the Medical Staff member present at the Medical Emergency Evaluation Code for MR1 on November 12, 2016. None was provided.

Interview with EMP1 on November 30, 2016, at 10 AM confirmed the "Medical Emergency Evaluation Code" for MR1 was inaccurately documented. EMP1 confirmed a Medical Staff member was not present at the Medical Emergency Code on November 12, 2016.

Interview with EMP6 on November 30, 2016, at 2 PM confirmed there was no documentation in MR1 of a written or verbal order from a Medical Staff member to transfer the patient in MR1 to the Emergency Department and there was no documentation of a Medical Staff member's progress note for the event on November 12, 2016.

Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) - Patient Rights - Notice of Rights
482.13(e)(5) -Patient Rights - Restraint or Seclusion
482.13(h) -Patient Rights - Patient Visitation Rights
482.23 - Nursing Services
482.41 - Physical Environment
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policy and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure accurate and consistent policies and procedures were available for nursing staff to reassess patients on Suicide Precautions (SP) for seven of seven medical records reviewed for nursing reassessments (MR1, MR7, MR8, MR9, MR31, MR32, MR33).

Findings include:

Review on November 30, 2016, of facility policy "Suicide Risk Assessment/ Reassessment, Observation and Interventions" reviewed July 14, 2016 revealed " ... B. Suicide Precautions: ... The inpatient Registered Nurse conducts a suicide risk reassessment daily using the "Suicide Risk Reassessment Form" to determine the need to maintain the same level of observation. ... C. Suicide Risk Reassessments: Individuals who are on a suicide precautions [sic] will be reassessed as follows: 1. RN reassessment, using the "Suicide Risk Reassessment Form" every shift ... ".

Review on November 29, 2016, of MR1 revealed the patient had a physician order for a Level 2 with Suicide Precautions. Further review of MR1 revealed there was only daily documentation of a nursing reassessment for Level 2 Suicide Precautions.

Review on December 2, 2016, of MR7, MR8, MR9, MR31, MR32 and MR33 revealed these patients had a physician order for Level 2 Suicide Precautions. Further review MR7, MR8, MR9, MR31, MR32 and MR33 revealed only daily documentation of a nursing reassessment for Level 2 Suicide Precautions.

Interview with EMP3 on November 30, 2016, at 2 PM confirmed RNs [nurses] do not conduct a Suicide Risk Reassessment on every shift; it is the practice of the facility to document an RN Suicide Risk Reassessment for Level 2 SP daily.

Interview with EMP8 on December 2, 2016, at 3 PM confirmed the "Suicide Risk Assessment/Reassessment" policy contained inconsistent procedures for nursing documentation and confirmed there were only daily RN Suicide Risk Reassessments for each patient in MR1, MR7, MR8, MR9, MR31, MR32 and MR33.

______________

Based on review of policy and procedures, review of facility document, review of medical record (MR) and interviews with staff (EMP), it was determined the facility failed to ensure that staff reported a change in behavior for one patient on Suicide Risk Precautions that resulted in the suicide death of the patient (MR1).

Findings include:

Review on November 29, and 30, 2016, of facility policy "Level of Observation" reviewed July 2016 revealed " ... II. Procedure: The Physician: ... will identify observation levels other than the minimum level of observations ... The physician initial Admission orders are to begin once the patient arrives to the inpatient unit. They will identify a specific precaution, each with a specified level of observation for: a. Suicide ... Nursing Staff: 5. The RN (inpatient or in the admissions area) may initiate precautions or increase the level of observation if the patient's condition changes ... "

Further review of this policy revealed " ... Levels of Observation ...

1. q [every] 15 minutes observation (Level 1)
a. Minimum level of observation for patients on the inpatients units ... staff will observe patient and document on the Patient Observation Sheet q 15 minutes. d. Assigned staff will make direct visual contact with patients and confirm they are not in danger or distress. e. Staff will be vigilant for potential risk factors identified for specific patients (levels of precaution), f. Staff spends sufficient time in bedroom and needs to observe the rise and fall of the chest ... to ensure the right patient is in the right bed noted every 15 mins ... g. 15 minute observations will occur at random intervals no longer than 15 minutes, rather than at strict and predictable 15 minute patterns. h. If a 15 minute observation missed please locate the patient to insure that [they] are safe, document on the back of the observation form ...

2. q 15 minute observation and identified precaution (Level 2) ...
e. Inpatient Nurses and MHT's [Mental Health Techs] will observe and document on the Patient Observation Sheet every 15 minutes.
f. Individual precautions (suicide, elopement, falls, etc.) ordered by the physician and followed by all staff.
g. staff will be vigilant for potential risk factors identified for specific patient's level of precautions.
i. Staff spends sufficient time in bedroom and needs to observe the rise and fall of the chest ... and to ensure the right patient is in right bed should be noted every 15 minutes."

Review on December 1, 2016, of facility document "Observation Record - 24 hours inpatient" document revealed 15 minute checks with comments/codes for location and activity of behavior of the patient and a space for staff initial. Review of the reverse side of the document revealed " ... Staff Responsibility When completing Observation Round - General safety check are to be completed while making rounds. This includes: unit cleanliness, identifying safety hazards and reporting of such, checking doors that should be locked. Monitor risk risk times: shower or bath times, room time, shift change, meal times, visiting hours, anytime staff attention may be diverted. Rounding is an an active responsibility; prior to entering a patient's room knock on the door. If a patient appears distressed, engage them and report any concerns to a unit nurse. Suicide Risk - Monitor closely uses of all personal hygiene items. Monitor closely for isolating behavior, hoarding sheets or other clothing to use in self harm. Insure retrieval of any and all writing instruments ... "

Review on December 1, 2016, of MR1's "Observation Record - 24 Hour Inpatient," dated November 12, 2016, revealed 15 minutes checks by staff documented the patient was in their room, lying down at 12:30, 12:45, 13:00, 13:15, 13:30,13:45, 14:00, 14:15, 14:30, and then again at 15:30, 15:45, 16:00.

Further review of MR1's Observation 24 hour inpatient documents dated November 8, through 11, 2016, revealed the patient's behavior/activity pattern for the same time periods documented on November 12, 2016, was documented that the patient was observed in the lounge or dining room. Continued review of MR1 revealed no documentation of communication or reporting to a nurse or a physician regarding the patient's change in behavior and location on November 12, 2016.

Review of nursing documentation for MR1 dated November 12, 2016, timed at 14:00 [2 PM| revealed " ... RN Daily Reassessment ... Is the individual currently verbalizing suicidal ideations or a desire to harm self? "N" (no) ... Pt was tearful during assessment ... Pt stated 'I'm freaking crazy. I deserve to die' ... Pt encouraged pt to seek staff when thoughts of suicide occur q [every] 15 minute safety rounds maintained. Pt remains safe."

Review of nursing documentation for MR1 dated 11/12/16 timed at 17:30 [5:30 PM] revealed " ... I last saw [patient] 15:56 [3:56 PM] walking past the nurses station to the laundry room with staff. At 16:15 [4:15 PM] [staff] came to me stating '[patient] hung [self].' I called for staff and ran to [patient's room] where I saw [patient] hanging from their top hinge by a sheet tied around neck. Code white and 911 were called. [Patient] was brought down to the floor and CPR was started, AED pads applied no shock advised x 4 EMS arrived [and they] continued CPR with AED, pushed IV meds/fluids and intubated. [Patient] then transported to [acute care]." There was no documentation that the RN initiated an increased Level of Observation at the time of MR1's reassessment at 2 PM or reported the change in the patient's behavior to a physician.

Telephone interview on December 1, 2016, with EMP7 at 12:45 PM confirmed they were the staff who did the observations documentation for MR1 on November 12, 2016. EMP7 confirmed the patient was observed lying on the bed in the patient's room and with eyes open.

Interview with EMP4 on December 1, 2016, at 4:30 PM confirmed the Observation Record for MR1 dated November 12, 2016, had documentation of a change of behavior and that the patient stated they 'deserved to die' was documented in the nursing reassessment note dated November 12, 2016, at 2 PM. EMP4 also confirmed there was no documentation in MR1 that the change of behavior reported to the nurse or patient reassessment behavior was reported to the physician. EMP4 confirmed the patient remained on a Level 2 Suicide Precaution observation status.

______________

Based on facility policy and procedures, review of medical record (MR), and interview with staff (EMP), it was determined the facility failed to ensure established policy and procedures were followed by staff for completion of an "Inpatient Transfer Form" for one of five medical records reviewed (MR1).

Findings include:

Review on November 30, 2016, of facility policy "Transfer to emergency room and Return of Individual to the Inpatient Unit," reviewed July 2016 revealed " ... IV. Procedure: ... 8. The RN will delegate to the appropriate staff: ... B. Completion of the Inpatient Transfer Form ... "

Review on November 30, 2016, of MR1 revealed no documentation of an "Inpatient Transfer Form" for November 12, 2016, when the patient required transfer to the acute care Emergency Department.

Interview on November 30, 2016, at 2 PM with EMP3 confirmed there was no documentation of an "Inpatient Transfer Form" for MR1 for the November 12, 2016, transfer to the Emergency Department.

Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) - Patient Rights - Notice of Rights
482.13(e)(5) - Patient Rights - Restraint or Seclusion
482.13(h) -Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.41 - Physical Environment
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, review of facility policy and procedures, review of medical record (MR), observation of patient care units and interview with staff (EMP), it was determined the facility failed to ensure a safe physical environment was provided to all patients and that resulted in one patient death from suicide (MR1).

Findings include:

Review of facility document dated November 13, 2016, revealed a patient suicide death by hanging on November 12, 2016.

Review on November 29, 2016, of MR1 revealed the patient was admitted to the facility on on [DATE], and transferred to an acute care Emergency Department on November 12, 2016, after the patient was found hanging by a sheet on a door hinge in the patient's room. The patient had been ordered Level 2 Suicide Precautions during the admission. The patient in MR1 was pronounced dead at the acute care Emergency Department on November 12, 2016.

Observation of patient care unit - TE1 on November 29, 2016, between 3PM and 4 PM revealed a 22 patient care adult general unit. Observation of Rooms 1, 2, 3, 4, 6, 9, 13, 17, 18 revealed exposed piping behind the toilet, elongated shower spout and knobs, elongated elongated vanity sink spout and knobs. There were windows with non safety type screws and wall mounted heater vents that were not completely attached to the wall surface and the temperature control knob and screws exposed with sharp edges. All beds on the unit were considered restraint beds with 9-11 openings on the side and foot of bed approximately 12 inches from the floor. Exit doors on the unit were identified by signs that were mounted approximately 2 inches from the ceiling and considered a "loopable possibility."

Observation of patient care unit TW1 unit on November 29, 2016, between 3 PM and 4 PM revealed a 22 patient care high-functioning adult general unit. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 were observed to have non-safety door hinges on rooms/offices occupied by support staff, housekeeping closets, linen rooms, laundry rooms. Exposed piping behind the toilet, elongated shower spout and knob, elongated vanity sink spout and knobs. There were windows with non safety type screws and wall mounted heater vents that were not completely attached to the wall surface and the temperature control knob and screws exposed with sharp edges. All beds on the unit were considered restraint beds with 9-11 openings on the side and foot of bed approximately 12 inches from the floor. The three Exit doors on the unit were identified by signs that were mounted approximately 2 inches from the ceiling and considered a "loopable possibility" Interview with EMP3 confirmed these observations during the tour.

Interview with EMP1 and EMP3 on November 29, 2016, between 3 PM and 4 PM confirmed observation tour findings and lack of completion status of patient care units.

Review on November 29, 2016, of facility document also dated November 29, 2016, revealed the facility had 192 patient beds, patient census was 166, Suicide Precautions were ordered for 125 patients-75.3% [of census].

Immediate Jeopardy was called on November 29, 2016, at 5 PM and removed at 9:30 PM after an acceptable Immediate Action Plan was received to eliminate immediate potential harm related to the unsafe physical environment and the number of patients on Suicide Precautions. An acceptable 30 day Action Plan was received on November 30, 2016, at 6 PM to ensure entire project completion of safety retrofits.

Review on November 29, 2016, of facility document dated January 2015 revealed environmental safety concerns were identified and reported to the Governing Body in May 2015.

Review on November 29, 2016, of Governing Board Meeting Minutes dated May 12, 2015, revealed "The anti-ligature project is progressing on schedule and on budget. 192 bedrooms and bathrooms will be retrofitted. Twenty two patient rooms as well as some of the communal restrooms have been completed thus far."

Review on November 29, 2016, of facility policy and procedures "Environmental Rounds" reviewed November 10, 2015, revealed "Friends Hospital will conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risk."

Review on November 29, 2016, of facility documents "Monthly Safety Inspection Checklist" dated October 2016 revealed the following for eight patient care units:

"Patient Bedrooms and Bathrooms
Unit BN1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit BN2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. Needs [checked].
Unit BS1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. Needs [checked].
Unit TE1 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit TE2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].
Unit TW1 ... 5. no documentation for patient bedrooms and bathrooms.
Unit TW2 ... 5. Doorknobs, hinges and shower fixtures have been retrofitted to prevent tie-off points to not support body weight. OK [checked].

Review on November 30, 2016, of facilty document revealed eight patient care units with status of completion of antiligature, piano hinges, door knobs and bed slats to cover loopable holes in bed frames as follows:

BN1 - Older Adult- 24 beds, completed for anti-ligature, piano hinges, knobs, bed slats completed on 23 beds, last bed scheduled for completion 11/30/16.
BS1 Intensive Adult - 26 beds, 24/26 beds completed for anti-ligature, all bed completed for piano hinges, door knobs replacement but still required bed slats for 26 rooms.
BN2- General Adult - 24 beds -all piano hinges completed, 21 rooms required anti-ligature, door knobs replacement and all 24 beds still required bed slats.
BS2- adolescent unit, 24 beds - all rooms completed for anti-ligature, piano hinges and door knobs replacment. All 24 beds required bed slats.
TW1- General Adult - 24 beds - all piano hinges, all 24 beds required anti-ligature, door knobs, bed slats.
TE1 - General Adult - 22 beds- all piano hinges vent were completed, all 22 beds required anti-ligature, door knobs and bed slats.
TW2- General Adult - 24 beds-all beds required bed slats, the anti-ligature, piano hinges, door knobs were completed.
TE2- General Adult -24 beds- all Piano hinges completed; still required anti-ligature, door knobs and bed slats not completed for all 24 beds.

Interview with EMP1 on November 30, 2016, at 10 AM confirmed the above unit safety replacement status and lack of completion of safety upgrades.

Review on December 2, 2016, of facility document for status update on physical environment status update regarding vent and a/c covers presented to surveyor on December 2, 2016, revealed the following % of completion for Vents and A/C covers for patient care units as follows:

TE2 - Vents completed 100%, 0% A/C covers.
TW2 - completed for vents and A/C covers.
TE1 - 100% vents, 0% A/C covers
TW1 - 100% vents, 0% A/C covers
BS2 - 96% vents and A/C covers
BN2 - 100% vents, A/C covers 13%
BS1 - 92% vents and A/C covers
BN1 - 71% vents and A/C covers

Interview with EMP10 on December 2, 2016, at 2:30 PM confirmed the above completion status of the vent and A/C covers. EMP10 also confirmed the Monthly Unit Inspections rounds were conducted by unit managers.

Interview on November 29, 2016, with EMP1 at 4 PM confirmed the environmental safety concerns were identified in January 2015, presented to the Governing Body in May 2015 and were not yet completed at the beginning of the investigation survey that began on November 29, 2016. Further interview with EMP1 confirmed the death of the patient in MR1 was the result of suicide by hanging with a bed sheet on the door hinge in the patient's room.

Cross Reference:
482.12 - Governing Body
482.13 - Patient Rights
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting
482.13(a)(1) Patient Rights - Notice of Rights
482.13(e)(5) Patient Rights - Restraint or Seclusion
482.13(h) Patient Rights - Patient Visitation Rights
482.22(c) - Medical Staff Bylaws
482.23 - Nursing Services