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.

ADVENTIST HEALTH ST HELENA 10 WOODLAND ROAD SAINT HELENA, CA 94574 Feb. 4, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, staff interviews, clinical record review, and facility document review, the facility failed to keep suicidal patients free from access to ligature risks when:

1. 1 of 10 patients created a ligature from bed sheets then utilized the base of the toilet in his bathroom and the bathroom door to hang himself resulting in his death (Refer to A0144); and
2. 1 of 10 patients created a ligature from bed sheets and briefly hung himself from his bathroom door resulting in a "near miss" event by strangulation (Refer to A0144).

The cumulative effect of this systemic problem resulted in the facility denying patients their right to receive care in a safe setting.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, staff interviews, clinical record review, facility document review, and photographic evidence review, the facility failed to keep suicidal patients safe and free from access to ligature risks when:

1. 1 of 10 patients created a ligature from bed sheets then utilized the base of the toilet in his bathroom and the bathroom door to hang himself resulting in his death; and
2. 1 of 10 patients created a ligature from bed sheets and briefly hung himself from his bathroom door resulting in a "near miss" event by strangulation.

An IMMEDIATE JEOPARDY (IJ) was identified on 1/31/19 at 1:30 p.m. under Physical Environment 482.41(a), A-701.

The IMMEDIATE JEOPARDY was abated on 2/1/19 at 12:20 p.m.

Findings:

1. Patient 1 was admitted to the facility's Behavioral Health Unit (BHU) on 12/19/18 on a "5150" hold [California Welfare and Institutions Code which allows for an involuntary 72-hour hold when a person is a danger to themselves or others] with diagnoses of Major Depression, suicidal thoughts with plan to kill himself, Obsessive-Compulsive Disorder, and alcohol dependence with withdrawal.

A tour of the Behavioral Health Unit, including the room where Patient 1 resided, was conducted on 1/16/19 at 10:12 a.m. In a concurrent interview, Administrative Staff C stated Patient 1 created an "apparatus" with torn bed sheets. She stated it consisted of two parts, one which Patient 1 placed around his neck and over the bathroom door and the other around the base of the toilet bowl which he held onto using his body weight to prevent the latch-less bathroom door from swinging open. Administrative Staff C stated it was her opinion that Patient 1 shredded his bed sheets to create a ligature and hid it in an unknown location in his room. She stated on 1/3/19 at approximately 6:15 a.m., Patient 1 was found unresponsive hanging from the inside of his bathroom door. She stated a "code blue" [an emergency response code called when a patient is unresponsive] was called at 6:20 a.m. Administrative Staff C stated, since the hanging death of Patient 1, all the bathroom doors on the BHU were removed on 1/7/19 and replaced with vinyl shower curtains held in place with Velcro and all patient sheets were removed from the beds on 1/5/19 and replaced with blankets.

During an interview on 1/17/19 at 1:30 p.m., Administrative Staff B stated after Patient 1's death, all the bedside cabinets were removed from the patient rooms. She stated they were removed for infection control reasons, and also because ligatures could be hidden in them.

During an interview on 1/24/19 at 9:20 a.m., Management Staff E was asked whose job it was to update patient Treatment Plans. He stated: "Any nurse" and that they should be "Updated every shift. Absolutely." When asked what his expectation was regarding BHU staff updating Patient 1's Treatment Plan, Management Staff E stated: "To update the plan." When asked if he would have expected Patient 1's bedsheets and bathroom door to be removed at the time he was making comments about use of these items to harm himself, Management Staff E stated: "Yes. It would have been prudent to update the Treatment Plan." When asked if he would have expected Patient 1 to be placed on 1-to-1 observation (i.e. Line-of-Sight) following his comments about being more suicidal in the morning hours, Management Staff E stated: "[we] could have done line of sight [patient is within arm's length of staff member at all times] during this time period." Management Staff E also stated facility staff should have been doing suicide risk assessments on every patient, every shift no matter if they scored "high," moderate," or "low" on the assessment.

During an interview and concurrent document review on 1/24/19 at 9:50 a.m., Social Worker W confirmed she wrote the following Social Service notes: 1) On 12/20/18--"Pt stated he has been depressed and feeling suicidal for over a year. Lately he has been thinking of ways to kill himself: alcohol poisoning, hanging self in bathroom, jumping off nearby bridge." 2) On 12/21/18--"Pt reports that he does not feel safe even while in the hospital." 3) On 12/27/18--"Pt stated he benefits from AA (Alcoholics Anonymous), but he is just scared to return home, and scared he will start drinking again." 4) On 12/31/18--"Pt is perseverating on his discharge plan." The note indicated Patient 1 was to be discharged home on 1/3/19 at 11 a.m. When asked if Patient 1 told her he planned to kill himself in the bathroom, Social Worker W stated Patient 1 told this both to herself and Physician G during his initial interview on 12/20/18. When asked if Patient 1 communicated to her why he did not feel safe in the facility, Social Worker W stated, "No," adding that there was just an "ongoing theme" that he wanted to hurt himself, but "he did not give specifics." When asked if she felt Patient 1 would kill himself prior to discharge, Social Worker W stated she did not as "he was ready. He was very happy and future oriented." She added: "He was definitely smart enough to pull this off."

During an interview and concurrent clinical record review on 1/24/19 at 10:10 a.m., Licensed Nurse J confirmed she wrote the following nursing note on 1/1/19 at 2:04 p.m.: "Patient reports mild anxiety d/t (due to) discharge and going back to life and dealing with sobriety." When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated: "No. I don't believe so. No. I should have. Yeah." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated: "I don't believe so. No." When asked if she ever checked for the presence or condition of Patient 1's bed sheets, she stated: "No. Not personally."

During an interview and concurrent clinical record review on 1/24/19 at 11 a.m., Physician H confirmed she was the Medical Director on the BHU and that she wrote the following Behavioral Health Progress Note in Patient 1's chart, dated 12/27/18: "'I still think about suicide sometimes, like when I get depressed about the future, it's an option that I find comforting...I feel pretty anxious'...Patient continues to have a pretty high level of anxiety and obsessionality. He is most worried about his potential to become suicidal and to kill himself while drinking. He has a high level of motivation not to drink, but says he has failed before and is worried about his ability to avoid drinking...Patient remains depressed, anxious, and continues to have suicidal thoughts." Physician H also confirmed she wrote the following Progress Note, dated 12/31/18: "'I'm doing OK, still having the worst time in the morning but it gets better'...The patient says that his worst time is first thing in the morning when he has some mild suicidal thoughts...His mom is concerned that this admission has been 'too short'...They describe a history of deceptive and manipulative behavior, consistent with his addiction to alcohol recently and drugs in the past. She reports that the family is concerned about his ability to maintain sobriety and his potential suicidality...He continues to have some obsessionality, specifically regarding his discharge." When asked if she ever considered placing Patient 1 on 1-to-1 observation during the morning hours when he stated he had the most thoughts of suicide, Physician H stated: "I did not. He repeatedly stated he'd go to staff and that he didn't have a plan." When asked if she would have expected Patient 1's bathroom door to be immediately removed following his comments of hanging himself in the bathroom (Social Worker note 12/20/18), Physician H stated: "I do agree, it should have been removed." When asked if she was aware of Patient 1 telling Physician G that he intended to utilize bed sheets to kill himself (Physician G's initial Psychiatric Evaluation dated 12/20/18), Physician H stated she was not aware of this, but responded "Yes" when asked if Patient 1's bed sheets should have been immediately removed from his bed following such comments. Physician H was asked if she was aware of Patient 1's comments to Physician G (Physician G's Progress Note dated 12/21/18) that he intended to kill himself "when opportunity to kill himself presents"? Physician H responded she was not aware of this. Physician H was asked, in light of all the above, was it her expectation that Patient 1's bed sheets and bathroom door should have been immediately removed from his access. She stated, "Yes." Physician H also stated she was aware Patient 1 "told his family he was not planning on leaving the unit alive," but that "no specifics" were given. Physician H was asked if she was aware of the two Ligature-Risk Assessments performed at the facility, one dated December 2017 and the other dated July 19, 2018. She stated: "Yes," but added she was not aware the the bathroom doors had been identified as "high risk" (for use with ligatures). Regarding the six month delay in removal of the bathroom doors from the BHU from the time they were first mentioned as a ligature-risk in July 2018 until the time they were finally removed on January 5-6, 2019 following the death of Patient 1, Physician H stated that was "not an acceptable length of time" and that it reflected "a lack of nursing leadership." Physician H also stated, in her opinion, the BHU should function as its own department so it and she as Medical Director "can have a seat at all tables." She also stated she was not part of the Ligature Risk Committee and this failure created a "lack of power to act."

During an interview on 1/24/19 at 12:55 p.m., Management Staff E was asked if Patient 1 could have crafted his ligature in between the time he was last seen alert (on 1/3/19 at 6 a.m. per the 15 minute Patient Observation Checklist when Patient 1 was seen going from his bed into his bathroom) and the time he was found unresponsive in the bathroom (on 1/3/19 at 6:20 a.m. per the Cardiopulmonary Resuscitation Record, dated 1/3/19). Management Staff E stated: "No. No. Of course not." He added he believed Patient 1 had been hiding the ligature somewhere in his room.

During an interview and concurrent clinical record review on 1/24/19 at 1 p.m., Physician G confirmed she wrote the following Psychiatric Evaluation note, dated 12/20/18, which indicated under "History of Present Illness:" "Pt (patient) says he has been researching how to kill himself. Pt says he wants to die somewhere where no one in his family will find him. Pt reports spending hours on the internet trying to figure out how to kill himself. Pt reports thinking of how to kill himself using the sheets here in the hospital..." Under "Physical Exam:" "Suicidal Ideation: Suicidal thoughts, plan and intent. Pt can not contract for safety." Under "Assessment/Plan:" "Pt currently on line of sight for safety reasons as pt at very high risk of suicide." Physician G also confirmed she wrote the following Behavioral Health Progress Note, dated 12/21/18: "Pt continues to be very suicidal. Pt reports ongoing suicidal thoughts. Pt reports he now has 3 plans for suicide here but only thinks one of them will work. Pt says he thinks about dying and suicide constantly to the exclusion of all else...Obsessing about suicide and the ways to kill himself here that might be effective...Suicidal thoughts, plans or intent. Will not divulge plans." Under "Reason for Continued Hospital Stay:" "Danger to self. Intent to kill himself when the opportunity to kill himself presents." Physician G confirmed she wrote the following Behavioral Health Progress Note, dated 12/21/18: "Pt says he attempted suicide here by 'drinking 5 gallons of water in less than an hour...I figured out that would kill me...I couldn't do it though...I threw up after 2 gallons of water'...Ruminative concerns about his future and his ability to get better." Physician G confirmed she wrote the following Behavioral Health Progress Note, dated 1/2/19: "Discussed pt's fears about his anxiety tomorrow [planned date of discharge]" and the following Discharge Summary note, dated 1/3/19, which indicated under "Hospital Course:" "The day of pt's death pt was found hanging in his bathroom on routine suicide checks...Pt was declared dead by asphyxiation at 6:54 a.m." Physician G confirmed that Patient 1 told her he was going to use bed sheets to kill himself. When asked why she did not immediately order that Patient 1's bed sheets be removed from his bed, she stated she did not "want to use draconian measures if she did not have to." When asked if she felt Patient 1 had the capability of carrying out his suicide plan, Physician G stated, "Yes." When asked if she believed Patient 1 could have created the ligature with bed sheets in 15 minutes, Physician G stated: "I wouldn't think so. He probably made it in the beginning when he was very suicidal and hid it for later use." When asked if she was aware that Patient 1 had increased thoughts of suicide in the morning hours, Physician G stated: "I was." When asked why she did not order that Patient 1 be placed on 1-to-1 observation during those hours, Physician G stated: "I thought we were out of that spot. I falsely believed he was ready for discharge and felt that was not warranted." When asked if she was aware that one of the ways Patient 1 mentioned killing himself was with the use of the bathroom door, Physician G stated she "knew he mentioned this." When asked why she did not immediately order the removal of Patient 1's bathroom door, Physician 1 stated she "didn't think to remove them" and that it would have been "demoralizing and demeaning" to do so. When asked if she was aware of the July 2018 Ligature Risk Assessment where the bathroom doors were classified as a "high" ligature risk, Physician G stated she was not aware of this. She added even if she were aware of this she still would not have ordered the door's removal because "you can hang from anything" including a toilet. "You don't need a door."

During an interview and concurrent clinical record review on 1/24/19 at 1:55 p.m., Licensed Nurse I confirmed she conducted Patient 1's admission assessment on 12/19/18 at 7:05 p.m. at which time he was thinking of harming or killing himself. Licensed Nurse I also confirmed she conducted Patient 1's Suicide/Self-Harm Risk Assessment on 12/19/18 at 6:25 p.m. at which time he had a score of 14 which indicated he was at "high risk" for suicide. Licensed Nurse I confirmed she wrote the following nursing note on 12/28/18 at 2:06 p.m.: "...pt denied si [suicidal ideation]...'I was earlier this am but not right now'" and the following nurses note on 12/19/18 at 6 p.m.: "...endorsed [positive] SI (suicidal ideation), 'constantly thinking about suicide.'" Review of Licensed Nurse I's Clinical Nursing Note, dated 12/19/18 at 6:25 p.m., indicated: "At around 1816 [6:16 p.m.] this writer received a phone call from pt's father [name of father] stating that, 'I just got off the phone with my son and he sounded very distraught'...Pt's father [name of father] further disclosed, 'my son said...your hospital security is weak...you guys do like every 15 minute checks...and he said that he could easily find something that he could kill himself with...like the bed sheet, he can tear it and hang himself with it and also did he tell you that he is writing a good bye letter to us stating that his intention is not to come back home?'...Pt...confirmed that he did called [sic] his father and said, 'something like that along the line.'" Licensed Nurse I stated she informed the charge nurse of the above conversation and notified the physician on-call of the situation and obtained an order to place Patient 1 on Line-of-Sight observation. When asked if she updated Patient 1's Treatment Plan following the telephone conversation with Patient 1's father or his suicidal ideation, Licensed Nurse I stated, "No." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated she just glanced around the room as checking under the mattress or in the bedside cabinet was "not part of the routine."

During an interview and concurrent clinical record review on 1/24/19 at 3:20 p.m., Licensed Nurse K confirmed she wrote the following nursing note on 12/25/18 at 1:38 p.m.: "Pt is isolative to room and self" as well as the nursing note on 12/23/18 at 1:34 p.m.: "...reported his mood is anxious 'from being here'...continued to endorse SI (suicidal ideation) with no specific plan 'there is nothing I can do in this place'...Pt is isolative to self, mostly remain in bed sleeping." When asked if she updated Patient 1's Treatment Plan regarding his anxiety and isolative behavior, she stated: "I don't think I did." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated she did not check under his mattress or in his bedside cabinet.

During an interview and concurrent clinical record review on 1/25/19 at 10 a.m., Licensed Nurse L confirmed she wrote the following nursing note on 12/20/18 at 11 a.m.: "Patient on LOS (line of sight) for DTS (danger to self). Endorses constant SI (suicidal ideation). Refuses to explain plan to this writer...Patient isolative to self...Drinking large amounts of water." When asked if she updated Patient 1's Treatment Plan regarding his suicidal ideation, isolative behavior, and drinking large amounts of water, Licensed Nurse L stated: "I did not." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated: "I did not." She added, "I don't know if they have a standard for searching rooms." When asked about who changes patients' bed sheets and how often they are changed, Licensed Nurse L stated it was up to the patients when their sheets are changed. They ask for a replacement set of sheets. "It is not a one-for-one exchange. Patients put the old sheets in the dirty linen."

During an interview and concurrent clinical record review on 1/25/19 at 12:46 p.m., Licensed Nurse V confirmed she wrote the following nursing note on 12/23/18 at 10:47 p.m.: "Patient on line of sight for suicidal ideation...Up for meals but mostly stays in his room." When asked if she updated Patient 1's Treatment Plan for his suicidal ideation and isolative behavior, Licensed Nurse V stated: "I did not." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated she did not and added that she would only look under the mattress if a patient was hoarding something. When asked if she ever checked for the presence or condition of Patient 1's bed sheets, she stated: "No." When asked if bed sheets are tracked or monitored by staff, Licensed Nurse V stated sheets are given to patients and that staff do not track how many sheets are given to patients. She added that patients change their own bed linens if they are well enough and that they do not need to turn in the old set of linens in order to get a new set of sheets.

During an interview and concurrent clinical record review on 1/25/19 at 1:16 p.m., Licensed Psych Tech M confirmed he wrote the following nursing note on 12/27/18 at 1:19 p.m.: "Pt admits to intermittent suicidal ideation...Concerned that after DC (discharge) he will relapse into drinking." When asked if he updated Patient 1's Treatment Plan regarding his suicidal ideation or concern after discharge, Licensed Psych Tech M stated it was the role of the licensed nurse to update the Treatment Plans rather than the techs.

During an interview and concurrent clinical record review on 1/25/19 at 1:40 p.m., Licensed Nurse X was asked if the rooms of suicidal patients are regularly checked for items they might use to harm themselves such as under the mattress or inside the bedside cabinet. She stated: "No. We don't lift the mattress" and the bedside cabinets are not checked daily. Licensed Nurse X stated staff just do a "visual" inspection around the room.

During an interview and concurrent clinical record review on 1/25/19 at 2 p.m., Licensed Nurse N confirmed she wrote the following nursing note on 12/30/18 at 9:14 p.m.: "States, I still have some suicidal thoughts, but just when I wake up in the morning. Then it goes away...When I drink it made my depression worse." Licensed Nurse N also confirmed she wrote the following nursing note on 12/28/18 at 9:56 p.m.: "Pt also reported to have SI (suicidal ideation) in the am but not now." When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated: "No, I didn't put it in the plan." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated she "just looks around the room" and that checking under the mattress or in the bedside cabinet was "not routinely done."

During an interview and concurrent clinical record review on 1/25/19 at 3:05 p.m., Licensed Nurse O confirmed he wrote the following nursing note on 12/22/18 at 2:40 p.m.: "Continues on line of sight for suicidal ideation. States he still feels unsafe and is still having suicidal ideation" as well as the following nursing note on 12/21/18 at 7:43 p.m.: "Continues on line of sight for suicidal ideation...Quiet and minimally interacts. Mostly in his room or on phone." When asked if he updated Patient 1's Treatment Plan regarding his suicidal ideation and isolative behavior, Licensed Nurse O stated: "I don't remember if I updated the treatment plan, but pretty sure I did not." He added the BHU is "very deficient in the treatment plans" and that they are only updated once per week by the Interdisciplinary Team (IDT) and that the only nurse who goes to the IDT meetings is the charge nurse. Licensed Nurse O continued saying the treatment plans are "canned" and "not individualized." When asked if, while caring for Patient 1, he ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, he stated: "No," adding this is not done on a routine basis. When asked if he ever checked for the presence or condition of Patient 1's bed sheets, he stated: "No." Specifically regarding Patient 1, Licensed Nurse O stated he felt Patient 1 "waited until he was on every 15 minute checks to have a 15 minute window to kill himself," adding that the suicide happened at the busiest time of night when the shifts are changing from the night shift to the day shift, labs are being drawn, weights are being done, and blood sugars are being checked.

During an interview and concurrent clinical record review on 1/29/19 at 10:07 a.m., Licensed Nurse P confirmed she wrote the following nursing note on 1/2/19 at 6:23 p.m.: "Pt reported feeling some mild anxiety regarding upcoming discharge to home tmrw (tomorrow) morning...'I will definitely have to stay away from alcohol. I'm nervous about that.'" When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated she did not recall that she did. When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated: "Not with this patient." When asked if she ever checked for the presence or condition of Patient 1's bed sheets, she stated: "No."

During an interview on 1/29/19 at 10:25 a.m., Licensed Nurse Y stated she was the person doing the every 15 minute checks on the night shift beginning on 1/3/19 at 5:45 a.m. She stated Patient 1 was asleep on her rounds at 5:45 a.m. When she checked him at 6 a.m., he had just woken up and saw Patient 1 get out of his bed and enter his bathroom. On her rounds at 6:15 a.m., Licensed Nurse Y stated Patient 1's bathroom door was "opened a slight crack" and this is when she found him hanging from his bathroom door. She then went and called for help. When asked if the rooms of suicidal patients are regularly checked for items they might use to harm themselves such as under the mattress or inside the bedside cabinet, Licensed Nurse Y stated: "We just look around [the room] for the most part. We don't search the rooms."

During an interview and concurrent clinical record review on 1/29/19 at 1:40 p.m., Licensed Nurse Q confirmed she wrote the following nursing note on 12/21/18 at 11:59 a.m.: Pt positive for SI (suicidal ideation) with a plan but did not want to express his plan...remains on LOS (line of sight). Pt isolative to room." When asked if she updated Patient 1's Treatment Plan regarding his suicidal ideation and isolative behavior, Licensed Nurse Q stated: "I don't think so. I guess I should have." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated: "No." When asked if she ever checked for the presence or condition of Patient 1's bed sheets, she stated: "No."

During an interview and concurrent clinical record review on 1/29/19 at 2:10 p.m., Licensed Nurse R confirmed he wrote the following nursing note on 12/27/18 at 9 p.m.: "He was worried about when he discharges and relapsing." When asked if he updated Patient 1's Treatment Plan regarding his worry/anxiety, he stated: "To be honest, no." When asked if, while caring for Patient 1, he ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, he stated: "No." When asked if he ever checked for the presence or condition of Patient 1's bed sheets, he stated: "No." Licensed Nurse R also stated Patient 1's bedside cabinet had a closed front with two drawers.

During an interview and concurrent clinical record review on 1/29/19 at 3 p.m., Licensed Psych Tech S confirmed she wrote the following nursing note on 1/1/19 at 2:04 p.m.: "He continues anxious about DC (discharge) and his ability to cope with being sober. He is leaving Thursday which he wanted. He worries about the burden his issues (ETOH [alcohol]/depression) create for his parents as he lives with them." She also confirmed she wrote the following nursing note on 12/30/18 at 10:29 a.m.: "Less depressed but does have fleeting thoughts of suicide especially in the morning when he wakes up." When asked if she updated Patient 1's Treatment Plan regarding his anxiety or morning suicidal thoughts, she stated: "No." When asked if, while caring for Patient 1, she ever checked under his mattress or in his bedside cabinet for the presence of items he could use to harm himself, she stated: "No." When asked if she ever checked for the presence or condition of Patient 1's bed sheets, she stated: "No."

During an interview on 1/29/19 at 3:28 p.m., Administrative Staff B stated there was no "prescriptive" policy regarding how often the suicide risk assessments are to be conducted based on assessment scores.

During an interview on 1/29/19 at 3:38 p.m., Administrative Staff B was asked if Patient 1 had a bedside table/stand in his bedroom prior to his death. She stated he did have a nightstand and that it had a closed front, as opposed to open shelving.

An IMMEDIATE JEOPARDY (IJ) was identified on 1/31/19 at 1:30 p.m. under Physical Environment 482.41(a), A-701. Administrative Staff A and B were notified of the IJ in Administrative Staff B's office.

During an interview with Administrative Staff A, B, and D, and Physician JJ and Facility Management Staff KK 1/31/19 at 2:15 p.m., the survey team requested the facility address the ligature risk created by the round knob handle in Hall B's shower (Hall A's shower was not in use).

Facility Plan of Action was accepted on 2/1/19 at 9:52 a.m. The Plan of Action indicated the immediate response for the toilets was: 1) Provide a sitter (designated staff member) for each patient room, in which ligature-resistant toilets have not been installed, to mitigate the ligature risk. a) Identify available sitter staff, who have MHU (mental health unit) related competencies, b) Reduce census/hold admissions patients as needed to meet available sitter staffing. 2) Continue clinical staff mitigation strategies, a) Search patients for contraband upon admission to the unit, b) Perform suicide risk assessment upon admission and on all patients on each shift, unless patient is sleeping, c) Patients who are identified at high risk for suicide will be placed on 1:1/Line of Sight surveillance (one staff for one patient), d) All patients receive checks every fifteen minutes, e) Sheets removed from beds, patients provided with blankets. 3) Continue to replace toilet bowls to ligature-resistant toilet bowls (flush to the back wall), with an anticipated date of completion for the entire unit being February 28, 2019. The current flush valves/tanks on the MHU meet the current design guidelines as ligature resistant, however the flush valves/tanks will eventually be replaced as well, a) As toilet bowls are replaced, the need for an assigned sitter to the room will be re-evaluated. The Immediate Response for Hall B shower was, 1) Provide one to one staffing by utilizing charge nurses for all patients taking showers, regardless of the patient's suicide risk status. The shower door is to remain ajar while the patient is in the shower, 2) Replace shower valve (handle to ligature-resistant handle), with anticipated date of completion no later than February 10, 2019. At the time the ligature-resistant handle is installed, the one to one for all patients will be discontinued.

The IMMEDIATE JEOPARDY was abated on 2/1/19 at 12:20 p.m. Administrative Staff B, C, and D were present in the Conference room when the IJ was abated.

During an interview on 2/4/19 at 11:35 a.m., Administrative Staff C was asked if the bathroom door should have been removed after the 7/19/18 Ligature/Self-Harm Risk Assessment. She stated, "In hindsight, yes, absolutely."

During an interview and concurrent electronic clinical record review on 2/4/19 at 1:25 p.m., Administrative Staff C stated Patient 1's Treatment Plan did not include interventions and documentation related to his comments about killing himself with hospital-provided bed sheets, hanging using the bathroom door, anxiety regarding his pending discharge or his plan to kill himself via water intoxication. In the same interview, Administrative Staff C was asked to show documentation of staff checking Patient 1's room for hidden ligatures, i.e. under his mattress or bedside cabinet. She was unable to do so. Administrative Staff C was asked if, after Patient 1's death, staff checked Patient 1's bed for the presence or condition of bed sheets. She stated there were no bed sheets on Patient 1's bed after his death. Administrative Staff C stated: "He used the whole sheet. He made two lanyards out of it." During the same interview and clinical record review, Clinical Data Analyst EE was asked if a suicide risk assessment was conducted for Patient 1 was after 12/25/18. She stated, "No."

Review of a nursing note by Licensed Nurse T, dated 12/22/18 at 9:18 p.m., who is no longer employed at the facility, indicated: "...isolative to self and room, reported depression 8/10, with intermittent SI (suicidal ideation), did not verbalized [sic] plan."

Review of a nursing note by Licensed Nurse U, dated 12/31/18 at 9:33 p.m., who is no longer employed at the facility, indicated: "Patient reports that his depression is worse in the morning. Pt states that he is anxious about discharge and is hoping that he will remain sober."

Review of Patient 1's Suicide/Self-Harm Risk Assessments indicated the following:

12/19/18 at 6:25 p.m. with a score of 14 (high risk)
12/20/18 at 8 a.m. with a score of 13 (high risk)
12/20/18 at 9:47 p.m. with a score of 11 (high risk)
12/21/18 at 8 a.m. with a score of 13 (high risk)
12/21/18 at 6 p.m. with a score of 5 (moderate risk)
12/21/18 at 8:52 p.m. with a score of 14 (high risk)
12/22/18 at 8 a.m. with a score of 4 (moderate risk)
12/25/18 at 9:23 p.m. with a score of 3 (low risk)

Review of the "1:1/Line of Sight Observation Records" indicated Patient 1 was on "Line of Sight" from 12/19/18 at 6:30 p.m. through 12/24/18 at 10:15 a.m.

Review of the facilit
VIOLATION: QAPI Tag No: A0263
Based on staff interviews, and facility document review, the facility failed to incorporate:

1. The anti-ligature risk assessment into its QAPI program (Refer to A283); and
2. The Physical Environment into its QAPI program (Refer to A701).

The cumulative effect of this systemic problem resulted in key Administrative staff being unaware of the anti-ligature risk assessment and its findings, along with the environmental projects associated with it, and the general condition of the physical plant.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on staff interviews and facility document review, the facility failed to incorporate 1) the anti-ligature risk assessments and mitigation efforts; and 2) the Physical Environment into its Quality Assurance and Performance Improvement (QAPI) program. This resulted in key administrative staff being unaware of the anti-ligature risk assessment and its findings, along with the environmental projects associated with it, and the general condition of the physical plant.

Findings:

1. During an interview and concurrent review of the facility's Performance Improvement binder on 1/25/19 at 11 a.m., Physician GG confirmed he was the current in-coming Chair of the Performance Improvement Committee. When asked if he attended any Performance Improvement Committee meetings in 2018, Physician GG stated, "No." When asked if he was aware of the December 20, 2017 or the July 19, 2018 Suicide/Self-Harm Assessments, Physician GG stated, "No." When asked if he was aware there were no Performance Improvement projects related to the assessments, Physician GG stated, "No."

During an interview and concurrent review of the facility's QAPI binder on 1/29/19 at 2:30 p.m., Physician HH confirmed he was the 2018 Chair of the Performance Improvement Committee. When asked if he was aware of the December 20, 2017 or the July 19, 2018 Suicide/Self-Harm Assessments and the findings that the patient bathroom doors on the Behavior Health Unit (BHU) were a "high" ligature risk, Physician HH stated he did not recall that specifically. He stated Performance Improvement projects are proposed by facility department managers and Administrative Staff B.

During an interview and concurrent PI binder review on 1/31/19 at 10 a.m., Administrative Staff B was asked why there were no Performance Improvement (PI) projects related to the two ligature risk assessments. She stated the assessments were handled through the Safety Committee which does not report to the PI Committee, but rather to the Governing Board.

Review of the 2018 "Performance Improvement Reporting Schedule" in the Performance Improvement (QAPI) binder found only one mention of the "Mental Health Unit" for the August 21, 2018 meeting. The topic of discussion was a "Plan-Do-Study-Act" regarding an improper legal hold. There was no mention of the anti-ligature risk assessments and the mitigation efforts.

Review of the 2018 "Performance Improvement Project Prioritization Grid" in the Performance Improvement binder found no mention of projects for the Behavioral Health Unit. Three projects were listed for the Senior Behavioral Health Unit related to "Inpatient Psychiatric Measures," "Tobacco Measures," and "Substance Abuse Measures." There was no mention of the anti-ligature risk assessments and the mitigation efforts.

2. During an interview and concurrent PI binder review on 1/31/19 at 10:20 a.m., Administrative Staff B stated construction projects for the physical environment are not managed through the Performance Improvement (QAPI) Committee.

Review of the 2018 "Performance Improvement Reporting Schedule" in the Performance Improvement binder found no mention of the facility's Physical Environment.

Review of the 2018 "Performance Improvement Project Prioritization Grid" in the Performance Improvement binder found no mention of projects for the facility's Physical Environment.

Review of the policy titled, "Quality Assurance/Performance Improvement Plan 2018-2019," revised 12/3/18, indicated: "As part of its quality assessment and performance improvement program, the organization must conduct performance improvement projects. a. The number and scope of distinct improvement projects conducted annually shall be proportional to the scope and complexity of the hospital's services and operations. b. The organization shall document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. c. While the organization is not required to participate in a CMS Quality Improvement Organization (QIO) cooperative project, its own projects shall be of comparable effort."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and record review, the facility failed to ensure:

1) Nursing staff updated and individualized patient treatment plans (Cross reference A- 396);

2) Patient suicide risk assessments were consistently performed (Cross reference 395); and

3) Nursing staff who floated (from their regularly assigned units) to the Behavioral Health Unit (BHU) possessed unit based competencies (skills) prior to providing and supervising care to patients (Reference A-397).

The cumulative effects of these systemic problems contributed to in the facility's inability to provide quality of care in a safe and effective manner.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure nursing staff consistently performed patient suicide risk assessments for 4 of 10 patients (Patients 2,5,7, and 8). This caused potential for inadequate evaluation and monitoring of patients known to be art risk for self-harm.

Findings:

1) Review of Patient 2's medical record with Management Staff C and EE on 1/22/19 indicated Patient 2 was admitted on [DATE] and placed on an involuntary hold (5150). Patient 2's physician psychiatric evaluation, dated 12/20/18, indicated he had gone to a park and tried to hang himself, but his caseworker had found and stopped him.

Review of Patient 2's nursing Suicide/Self-Harm Risk assessment, dated 12/25/18,
indicated #6 (Moderate Risk). Interventions were not identified.

Review of Patient 2's physician progress, dated 12/26/18, indicated nursing had called Physician H after Patient 2 tried to hang himself on the unit (using ripped bed sheets).

Review of Patient 2's nursing Suicide/Self-Harm Risk assessment after his attempted suicide, dated 12/26/18 at 2 p.m., indicated #15 (High Risk was 10+).

Patient 2's next nursing Suicide/Self-Harm Risk assessment was documented 12/27/18 at 10:09 p.m. (approximately thirty two hours later) and was #8 (Moderate Risk). Interventions were not documented.

During an interview on 2/4/19 at 2:25 p.m., Management Staff C confirmed no additional Suicide/Self-Harm Risk assessments were located in Patient 2's medical record from 12/25/18 through 12/27/18.

Review of facility policy titled, "Mentally Disturbed and Suicide/Violence Risk Assessment," subtitled, "Policy: Compliance - Key Elements," further subtitled, "J. Suicide or Homicide Precautions: Behavioral Health," (revised 5/16/17) indicated, "7. A reassessment, including suicide risk when clinically indicated, will be performed for any patient....who indicates the possibility that suicidal ideation or intent has increased."

2) Review of Patient 5's medical record with Management Staff EE on 1/30/19 at 1:10 p.m. indicated Patient 5 was admitted on [DATE] and placed on an involuntary hold (5150) due to voicing suicidal thoughts. Patient 5's physician psychiatric evaluation, dated 12/30/18, indicated the patient did not feel safe at home and wanted to hurt herself by hanging. The evaluation indicated Patient 5 had had a recent hospitalized from [DATE] - 12/26/18 for wanting to hurt herself by attempted overdose on medication.

Review of Patient 5's nursing Suicide/Self-Harm Risk assessment, dated 12/29/18 (admitted ), indicated #8 (Moderate Risk). Interventions included, "Reassess suicide risk daily."

Review of Patient 5's nursing Suicide/Self-Harm Risk assessment, dated 12/30/18 indicated #4 (Moderate Risk). Interventions included, "Reassess suicide risk daily."

A nursing Suicide/Self-Harm Risk assessment was not located in Patient 5's medical record for 12/31/18. During an interview on 1/30/18 at 1:10 p.m., Manager EE confirmed Patient 5 did not have a suicide risk assessment on 12/31/18 and stated she only had a total of three in her record (12/29/18, 12/30/18, and 1/2/18).

3) Review of Patient 7's medical record with Management Staff EE on 1/30/19 at 1:10 p.m. indicated Patient 7 was admitted on [DATE] and placed on an involuntary hold (5150) due to having suicidal thoughts. Patient 7's physician psychiatric evaluation, dated 1/2/19, indicated this was his fourth hospitalization (psychiatric).

Review of Patient 7's nursing Suicide/Self-Harm Risk assessment, dated 1/1/19 (admitted ), indicated #6 (Moderate Risk). Interventions included, "Reassess suicide risk daily."

A nursing Suicide/Self-Harm Risk assessment was not located in Patient 7's medical record for 1/2/19. During an interview on 1/30/18 at 1:10 p.m., Manager EE confirmed Patient 7 did not have a suicide risk assessment on 1/2/19.

Review of Patient 7's nursing Suicide/Self-Harm Risk assessment, dated 1/3/19, indicated he continued to be at a Moderate Risk (score of 6).

4) Review of Patient 8's medical record with Management Staff EE on 1/30/19 at 1:10 p.m. indicated Patient 8 was admitted on [DATE] and placed on an involuntary hold (5150) due to a suicidal plan to overdose on her psychiatric medication. Her physician discharge summary, dated 1/2/18, indicated Patient 8 reported multiple past suicide attempts.

Review of Patient 8's nursing Suicide/Self-Harm Risk assessment, dated 6/26/18 (admitted ), indicated #5 (Moderate Risk).

No other nursing Suicide/Self-Harm Risk assessment were located in Patient 8's medical record until her date of discharge on 7/2/18 (approximately seven days later). Manager EE confirmed Patient 8's medical record contained only two nursing suicide risk assessments (6/26/18 and 7/2/18).
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure nursing staff updated and individualized patient care treatment plans for 2 of 10 patients (Patient's 1 and 2) when:

1) Patient 1's Treatment Plan did not include interventions and documentation related to his comments about killing himself with hospital-provided bed sheets, hanging using the bathroom door, anxiety regarding his pending discharge or his plan to kill himself via water intoxication; and

2) Patient 2's Treatment Plan did not include interventions and documentation regarding two incidents: First incident on 12/15/18, when Patient 2 ripped bed sheets in an attempt to create a ligature (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation); Second incident on 12/26/18, when Patient 2 attempted suicide by hanging (utilizing ripped bed sheets).

These failures potentially prevented staff from developing, communicating, and implementing strategies to address Patient 1 and Patient 2's plans and execution of self-harm.

(A nursing Treatment Plan contains relevant patient information including goals/treatments, is updated with changes/new information, and is evaluated for effectiveness. The Treatment Plan promotes communication/collaboration between nursing and other healthcare professionals with an end goal of addressing changing patient care needs).

Findings:

1) During an interview and concurrent clinical record review on 1/24/19 at 10:10 a.m., Licensed Nurse J confirmed she wrote the following nursing note on 1/1/19 at 2:04 p.m.: "Patient reports mild anxiety d/t (due to) discharge and going back to life and dealing with sobriety." When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated: "No. I don't believe so. No. I should have. Yeah."

During an interview on 1/24/19 at 9:20 a.m., Management Staff E was asked whose job it was to update patient Treatment Plans. He stated: "Any nurse" and that they should be "Updated every shift. Absolutely." When asked what his expectation was regarding BHU staff updating Patient 1's Treatment Plan, Management Staff E stated: "To update the plan." When asked if he would have expected Patient 1's bedsheets and bathroom door to be removed at the time he was making comments about use of these items to harm himself, Management Staff E stated: "Yes. It would have been prudent to update the Treatment Plan."

During an interview and concurrent clinical record review on 1/24/19 at 1:55 p.m., Licensed Nurse I confirmed she conducted Patient 1's admission assessment on 12/19/18 at 7:05 p.m. at which time he was thinking of harming or killing himself. Licensed Nurse I also confirmed she conducted Patient 1's Suicide/Self-Harm Risk Assessment on 12/19/18 at 6:25 p.m. at which time he had a score of 14 which indicated he was at "high risk" for suicide. Licensed Nurse I confirmed she wrote the following nursing note on 12/28/18 at 2:06 p.m.: "...pt denied si [suicidal ideation]...'I was earlier this am but not right now'" and the following nurses note on 12/19/18 at 6 p.m.: "...endorsed [positive] SI (suicidal ideation), 'constantly thinking about suicide.'" Review of Licensed Nurse I's Clinical Nursing Note, dated 12/19/18 at 6:25 p.m., indicated: "At around 1816 [6:16 p.m.] this writer received a phone call from pt's father [name of father] stating that, 'I just got off the phone with my son and he sounded very distraught'...Pt's father [name of father] further disclosed, 'my son said...your hospital security is weak...you guys do like every 15 minute checks...and he said that he could easily find something that he could kill himself with...like the bed sheet, he can tear it and hang himself with it and also did he tell you that he is writing a good bye letter to us stating that his intention is not to come back home?'...Pt...confirmed that he did called [sic] his father and said, 'something like that along the line.'" Licensed Nurse I stated she informed the charge nurse of the above conversation and notified the physician on-call of the situation and obtained an order to place Patient 1 on Line-of-Site observation. When asked if she updated Patient 1's Treatment Plan following the telephone conversation with Patient 1's father or his suicidal ideation, Licensed Nurse I stated, "No."

During an interview and concurrent clinical record review on 1/24/19 at 3:20 p.m., Licensed Nurse K confirmed she wrote the following nursing note on 12/25/18 at 1:38 p.m.: "Pt is isolative to room and self" as well as the nursing note on 12/23/18 at 1:34 p.m.: "...reported his mood is anxious 'from being here'...continued to endorse SI (suicidal ideation) with no specific plan 'there is nothing I can do in this place'...Pt is isolative to self, mostly remain in bed sleeping." When asked if she updated Patient 1's Treatment Plan regarding his anxiety and isolative behavior, she stated: "I don't think I did."

During an interview and concurrent clinical record review on 1/25/19 at 10 a.m., Licensed Nurse L confirmed she wrote the following nursing note on 12/20/18 at 11 a.m.: "Patient on LOS (line of sight) for DTS (danger to self). Endorses constant SI (suicidal ideation). Refuses to explain plan to this writer...Patient isolative to self...Drinking large amounts of water." When asked if she updated Patient 1's Treatment Plan regarding his suicidal ideation, isolative behavior, and drinking large amounts of water, Licensed Nurse L stated: "I did not."

During an interview and concurrent clinical record review on 1/25/19 at 12:46 p.m., Licensed Nurse V confirmed she wrote the following nursing note on 12/23/18 at 10:47 p.m.: "Patient on line of sight for suicidal ideation...Up for meals but mostly stays in his room." When asked if she updated Patient 1's Treatment Plan for his suicidal ideation and isolative behavior, Licensed Nurse V stated: "I did not."

During an interview and concurrent clinical record review on 1/25/19 at 1:16 p.m., Licensed Psych Tech M confirmed he wrote the following nursing note on 12/27/18 at 1:19 p.m.: "Pt admits to intermittent suicidal ideation...Concerned that after DC (discharge) he will relapse into drinking." When asked if he updated Patient 1's Treatment Plan regarding his suicidal ideation or concern after discharge, Licensed Psych Tech M stated it was the role of the licensed nurse to update the Treatment Plans rather than the techs.

During an interview and concurrent clinical record review on 1/25/19 at 2 p.m., Licensed Nurse N confirmed she wrote the following nursing note on 12/30/18 at 9:14 p.m.: "States, I still have some suicidal thoughts, but just when I wake up in the morning. Then it goes away...When I drink it made my depression worse." Licensed Nurse N also confirmed she wrote the following nursing note on 12/28/18 at 9:56 p.m.: "Pt also reported to have SI (suicidal ideation) in the am but not now." When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated: "No, I didn't put it in the plan."

During an interview and concurrent clinical record review on 1/25/19 at 3:05 p.m., Licensed Nurse O confirmed he wrote the following nursing note on 12/22/18 at 2:40 p.m.: "Continues on line of sight for suicidal ideation. States he still feels unsafe and is still having suicidal ideation" as well as the following nursing note on 12/21/18 at 7:43 p.m.: "Continues on line of sight for suicidal ideation...Quiet and minimally interacts. Mostly in his room or on phone." When asked if he updated Patient 1's Treatment Plan regarding his suicidal ideation and isolative behavior, Licensed Nurse O stated: "I don't remember if I updated the treatment plan, but pretty sure I did not." He added the BHU is "very deficient in the treatment plans" and that they are only updated once per week by the Interdisciplinary Team (IDT) and that the only nurse who goes to the IDT meetings is the charge nurse. Licensed Nurse O continued saying the treatment plans are "canned" and "not individualized."

During an interview and concurrent clinical record review on 1/29/19 at 10:07 a.m., Licensed Nurse P confirmed she wrote the following nursing note on 1/2/19 at 6:23 p.m.: "Pt reported feeling some mild anxiety regarding upcoming discharge to home tmrw (tomorrow) morning...'I will definitely have to stay away from alcohol. I'm nervous about that.'" When asked if she updated Patient 1's Treatment Plan regarding his anxiety, she stated she did not recall that she did.

During an interview and concurrent clinical record review on 1/29/19 at 1:40 p.m., Licensed Nurse Q confirmed she wrote the following nursing note on 12/21/18 at 11:59 a.m.: Pt positive for SI (suicidal ideation) with a plan but did not want to express his plan...remains on LOS (line of sight). Pt isolative to room." When asked if she updated Patient 1's Treatment Plan regarding his suicidal ideation and isolative behavior, Licensed Nurse Q stated: "I don't think so. I guess I should have."

During an interview and concurrent clinical record review on 1/29/19 at 2:10 p.m., Licensed Nurse R confirmed he wrote the following nursing note on 12/27/18 at 9 p.m.: "He was worried about when he discharges and relapsing." When asked if he updated Patient 1's Treatment Plan regarding his worry/anxiety, he stated: "To be honest, no."

During an interview and concurrent clinical record review on 1/29/19 at 3 p.m., Licensed Psych Tech S confirmed she wrote the following nursing note on 1/1/19 at 2:04 p.m.: "He continues anxious about DC (discharge) and his ability to cope with being sober. He is leaving Thursday which he wanted. He worries about the burden his issues (ETOH [alcohol]/depression) create for his parents as he lives with them." She also confirmed she wrote the following nursing note on 12/30/18 at 10:29 a.m.: "Less depressed but does have fleeting thoughts of suicide especially in the morning when he wakes up." When asked if she updated Patient 1's Treatment Plan regarding his anxiety or morning suicidal thoughts, she stated: "No."

During an interview and concurrent electronic clinical record review on 2/14/19 at 1:25 p.m., Administrative Staff C stated Patient 1's Treatment Plan did not include interventions and documentation related to his comments about killing himself with hospital-provided bed sheets, hanging using the bathroom door, anxiety regarding his pending discharge or his plan to kill himself via water intoxication.

Review of the policy titled, "Mentally Disturbed and Suicide/Violence Risk Assessment," revised 5/16/17, indicated: "If the screening tool score indicates low risk, patient is left on usual supervision checks. Include findings in the treatment planning process. If the screening tool score indicates moderate or high risk, notify physician and discuss appropriate level of supervision. Including findings in the treatment planning process."

Review of the policy titled, "SBHP Treatment Planning Process," revised 7/12/18, indicated: "Each patient admitted to the Program has an individualized written treatment plan that is based on interdisciplinary clinical assessments. The treatment planning process is continuous and dynamic, beginning at the time of admission and continuing through discharge...Define specific interventions which comprise the treatment that will be utilized to help patient achieve short-and long-term goals on the Individual Treatment Plans...Each patient is reassessed to determine current clinical problems, needs and responses to treatment...Reviews occur when major clinical changes occur and at least every 7 days minimally or more often if clinically indicated."

2) Review of Patient 2's admit Psychiatric Evaluation, dated 12/20/18, indicated Patient 2's reason for admission was, "danger to self." Physician H documented the day prior (12/19/18), Patient 2 reported he had tried to hang himself in a park and his caseworker found him and stopped him.

Review of Patient 2's physician progress note, dated 12/25/18 (eleven days before he attempted suicide), indicated, "Patient was ripping up sheets 2 days ago to hang himself." Physician CC documented that Patient 2 stated, "Last night I saw the sheet that was ripped and I thought about hanging myself but I had someone watching me last night so I didn't."

Review of Patient 2's Nurse Clinical Note, dated 12/25/18, indicated Patient 2 had taken
Licensed Nurse K to his room and showed her that "two days ago, he started ripping off his bed sheet to use it for hanging self."

Review of Patient 2's Nurse Clinical Note, dated 12/26/18 (one day later) indicated Patient 2 had taken Licensed Nurse DD to his bathroom (in his room) and showed her, "a noose that he made with his bed sheet." Licensed Nurse DD documented she assessed Patient 2's neck, which was red in color. Licensed Nurse DD documented Patient 2 could "not finish" because the nurse came by and knocked on the door doing the fifteen minute safety checks.

Review of Patient 2's physician progress, dated 12/26/18, indicated nursing had called Physician H after Patient 2 tried to hang himself on the unit. Physician H documented Patient 2 had "produced a shredded sheet from which he had made a ligature." Physician H documented Patient 2 reported he had been attempting to hang himself with it in his bathroom, having tied it to a hinge on the door, but was interrupted when staff came to do 15 min (minute) checks." Physician H documented she assessed Patient 2 and he had some [DIAGNOSES REDACTED] (redness) on his neck, with no swelling.

During an interview on 2/1/19 at 11:15 a.m., Licensed Nurse DD stated Patient 2 told her (on 12/26/18) he had done something in the bathroom and he would show her what had happened. Licensed Nurse DD stated Patient 2 took her to his bathroom and showed her a sheet tied to the top hinge (of the bathroom door). She stated Patient 2 told her he had torn the sheet and looped it through the top hinge and stated a girl knocked on the door and interrupted him. Licensed Nurse DD assessed Patient 2's neck, which had red mark lines on the right and left sides of his neck.

Review of Patient 2's nursing treatment plan titled, "Master Treatment Plan", dated 12/19/18 indicated Patient 2 had safety/unsafe behaviors and under heading "Supportive Information," staff documented, "plan hang self." Review of Patient 2's nursing treatment plan titled, "Treatment Plan: Problem #1 Unsafe Behaviors: Danger to self," (dated 12/19/18) staff documented "plan hang self, insomnia." The treatment plan indicated the following interventions: "Close observation every 15 minutes...Educate patient regarding reporting when feeling unsafe or having impulses to hurt self/others...encourage patient to contact staff when feeling unsafe, assist patient with developing new strategies for interrupting thought(s) of unsafe behaviors." Neither treatment plan contained documentation of the 12/25/18 incident or identified updated interventions addressing Patient 2's behavior of making ligatures from bed sheets. Neither treatment plan contained documentation of Patient 2's suicide attempt the following day, 12/26/18, or identified updated interventions to address his behavior of self-harm.

During an interview and review of Patient 2's care plans on 2/4/19 at 2:25 p.m., Administrative Staff C was asked what interventions were identified by staff to keep Patient 2 safe after his attempted suicide by hanging on 12/26/18. Administrative Staff C stated she could not locate interventions in the treatment plan. When asked if staff had updated the treatment plan regarding his attempted suicide using ripped bed sheets, she stated she could not locate any updated information in the treatment plan.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on observation, interview and record review, the facility failed to ensure nursing staff (Licensed Nurse DD and Licensed Nurse LL) who floated (from their regularly assigned units) to the Behavioral Health Unit (BHU) possessed unit based competencies (skills) prior to providing and supervising care to patients. This caused potential for the facility's inability to provide quality care in a safe and effective manner.

Findings:

1) Review of Patient 2's admit Psychiatric Evaluation (documented by Physician H), dated 12/20/18, indicated his reason for admission was a, "danger to self" and had tried to hang himself prior to admission.

Review of Patient 2's Nurse Clinical Note, dated 12/25/18, indicated Patient 2 had taken
Licensed Nurse K to his room and showed her that he had, "started ripping off his bed sheet to use it for hanging self."

Review of Patient 2's physician progress, dated 12/26/18, indicated nursing had called Physician H after Patient 2 tried to hang himself on the unit. Physician H documented Patient 2 had "produced a shredded sheet from which he had made a ligature." Physician H documented Patient 2 reported he had been attempting to hang himself with it in his bathroom,

During an interview on 2/1/19 at 11:15 a.m., Licensed Nurse DD stated she usually worked on another unit and had floated (work on a unit other than usual unit) to BHU the day Patient 2 had tried to hang himself. Licensed Nurse DD stated Patient 2 took her to his bathroom and showed her a sheet tied to the top hinge (of the bathroom door). She stated Patient 2 told her he had torn the sheet and looped it through the top hinge of the door and stated a girl knocked on the door and interrupted him.

During the same interview on 2/1/19, Licensed Nurse DD was asked how she was trained to work on the BHU. She stated she had attended a CPI training (managing difficult situations and disruptive behaviors) and had shadowed (worked with/observed) a BHU nurse for one eight hour shift. She stated she had requested additional training (a second eight hour shift) because she had not had not been trained in admissions, discharges or legal holds. She stated the prior Manager had refused to give her additional training. When asked if she had been trained in ligature risks, she stated, "no." When asked if she knew toilets were a ligature risk, she stated, "no." She stated she had learned to monitor patient clothing (as they were ligature risks) but she was not told bed sheets were ligature risks.

During the same interview on 2/1/19, Licensed Nurse DD stated she reported Patient 2's attempted suicide to her manager (Management Staff NN). Licensed Nurse DD stated Management Staff NN obtained a competency check list for her and she and the nurse with whom she shadowed filled it out. Licensed Nurse DD stated she completed and signed her BHU competencies after the incident with Patient 2 on 12/26/18.

Review of facility document titled, "Registry/Float Orientation," subtitled, "Mental Health Unit" (dated 8/15/18), revealed Licensed Nurse DD signed her competency checklist on 1/2/19. Her orienting nurse signed it 12/28/18.

During an interview and review of Licensed Staff DD's timesheets on 2/4/19 at 11:50 a.m., Management Staff MM stated Licensed Staff DD had worked thirteen shifts on the BHU before her competencies were assessed and documented.

During and interview on 2/4/19 at 12:05 p.m., Management Staff NN stated Licensed Nurse DD had shadowed a BHU nurse on 8/15/18 but competencies were not filled out (documented on the competency checklist) at that time. She stated the BHU nurse signed it oon 1/2/19 and Licensed Nurse DD signed it on 1/2/19.

Review of facility policy titled "Competency Assessment," subititled, "Summary" (reviewed 11/15) indicated, "In order to provide safe and appropriate level of nursing care, the skills of personnel need to be assessed and documented. This is particularly key when personnel must float to other areas...All staff members complete a specific competency assessment during the orientation....to a new department or role."

2) During an interview and concurrent personnel file review on 1/30/19 at 12:45 p.m., Management Staff MM stated there was no documentation that Licensed Nurse LL had demonstrated competency on the Behavioral Health Unit (BHU). Management Staff MM stated Licensed Nurse LL was a "float" nurse whose home floor was a Medical-Surgical unit. Review of Licensed Nurse LL's time sheets from 1/1/18 to 1/30/19 indicated she worked on the Behavioral Health Unit five times on 7/9/18, 11/20/18, 12/16/18, 12/24/18, and 12/26/18. In a concurrent interview, Administrative Staff C stated she checked with the staffing office regarding Licensed Nurse LL's BHU competencies but there were none.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, interview and record review, the facility failed to ensure a safe environment for patients when:

1) 10 of 10 resident toilets on the Behavioral Health Unit (BHU) posed a ligature risk (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). This failure contributed to the suicidal death of one patient (Patient 1) and created potential for self-harm by other suicidal patients on the Behavioral Health Unit (Cross reference A-701)

An IMMEDIATE JEOPARDY (IJ) was identified on 1/31/19 at 1:30 p.m. under Physical Environment 482.41(a), A-701.

The IMMEDIATE JEOPARDY was abated on 2/1/19 at 12:20 p.m.;

2) 2.a.) The anti-ligature risk assessments and mitigation efforts and 2.b.) the Physical Environment were not incorporated into its Quality Assurance and Performance Improvement (QAPI) program. This contributed to key Administrative staff being unaware of the anti-ligature risk assessment and its findings, along with the environmental projects associated with it, and the general condition of the physical plant (Cross reference A-701);

The cumulative effects of these systemic problems resulted in the facility's inability to provide care in a safe environment.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, interview and record review, the facility failed to ensure a safe environment for patients when:

1)10 of 10 patient toilets on the Behavioral Health Unit (BHU) posed a ligature risk (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation).

This failure contributed to the suicidal death of one patient (Patient 1) and created potential for self-harm by suicidal patients on the BHU.

An IMMEDIATE JEOPARDY (IJ) was identified on 1/31/19 at 1:30 p.m. under Physical Environment 482.41(a), A-701.

The IMMEDIATE JEOPARDY was abated on 2/1/19 at 12:20 p.m.; and

2.a.) The anti-ligature risk assessments and mitigation efforts and 2.b.) the Physical Environment were not incorporated into its Quality Assurance and Performance Improvement (QAPI) program. This contributed to key Administrative staff being unaware of the anti-ligature risk assessment and its findings, along with the environmental projects associated with it, and the general condition of the physical plant.

Findings:

1) During a tour and concurrent interview on the BHU on 1/16/19 at 10:15 a.m., plastic coverings (similar to shower curtains) were being used as doors in patient bathrooms. Administrative Staff C stated the wooden bathroom doors had been removed. Management Staff E (Manager E) stated Patient 1 had utilized two ligatures (the bathroom door and the toilet) during his suicide attempt (approximately two weeks earlier). Manager E stated Patient 1 had ripped a bed sheet to make a noose and placed the noose around his neck. Manager E stated Patient 1 tied a portion of the sheet around the toilet base (the toilet in his bathroom) and put a portion of the sheet over the door. Manager E stated staff found Patient 1 in the bathroom when they came to his room for a routine, Q15 minute (every fifteen minute) safety check.

Review of Patient 1's physician discharge summary note, dated 1/3/18, indicated Patient 1 was , "...thinking of how to kill himself using the sheets here in the hospital..." Physician G documented on the day of his death, Patient 1 was, "found hanging in his bathroom on routine suicide checks...Pt was declared dead by asphyxiation at 6:54AM."

During a guided tour of the BHU (which consisted of Halls A and B) on 1/23/19 between 10 a.m. and 11:28 a.m., the toilets (bowl and base) in patient bathrooms 340, 335, 334, 333, 330 were not flush to the wall (no space between toilet bowl/base and wall); space existed between the toilet bowl/base and the wall (where a ligature could be fastened). The patient shower on Hall B had a large, round water-control knob handle. Manager E was asked if the knob handle was an anti-ligature fixture. Manager E stated the round, knob-handle was not anti ligature (it posed a ligature risk).

During an interview on 1/23/19 at 11:28 a.m., Mental Health Technician (MHT) BB. stated there were six toilets in Hall A patient bathrooms.

Review of the BHU's census dated, 1/16/19, indicated there were ten rooms (with bathroom toilets) on the unit (rooms 331 - 341).

Review of facility Risk Assessment titled, "Ligature/Self-Harm Risk Assessment," (Senior Behavioral and Mental Health unit) subtitled "Level IV Area (Patient Room Bathrooms)," further subtitled, "12. Bathroom Features" (dated July 19, 2018) indicated ligature-resistant toilets did not allow for looping, had solid bottom that extended to floor and wall, and the toilet was flush to the wall. The Risk Assessment indicated, "All toilets have ligature points" and follow-up repair was needed. The document indicated, "Replace with ligature-resistant toilets and flush valves." The assessment indicated after corrective action was completed, the facility should, "reassess to determine if any remaining risks remain." The document indicated the corrective action was to replace the toilets with ligature-resistant toilets. The Risk Assessment indicated the risk level was, "high" based on, "Scope-Widespread, Likelihood - High." The Risk Assessment indicated toilet replacement had not been started as of 7/20/18 (more than five months prior to Resident 1's death).

An IMMEDIATE JEOPARDY (IJ) was identified on 1/31/19 at 1:30 p.m. under Physical Environment 482.41(a), A-701. Administrative Staff A and B were notified of the IJ in Administrative Staff B's office.

During an interview with Administrative Staff A, B, and D, and Physician JJ and Facility Management Staff KK 1/31/19 at 2:15 p.m., the survey team requested the facility address the ligature risk created by the round knob handle in Hall B's shower (Hall A's shower was not in use).

Facility Plan of Action to abate the IJ was accepted on 2/1/19 at 9:52 a.m. The Plan of Action indicated the immediate response for the toilets was: 1) Provide a sitter (designated staff member) for each patient room, in which ligature-resistant toilets have not been installed, to mitigate the ligature risk. a) Identify available sitter staff, who have MHU (mental health unit) related competencies, b) Reduce census/hold admissions patients as needed to meet available sitter staffing. 2) Continue clinical staff mitigation strategies, a) Search patients for contraband upon admission to the unit, b) Perform suicide risk assessment upon admission and on all patients on each shift, unless patient is sleeping, c) Patients who are identified at high risk for suicide will be placed on 1:1/Line of Sight surveillance (one staff for one patient), d) All patients receive checks every fifteen minutes, e) Sheets removed from beds, patients provided with blankets. 3) Continue to replace toilet bowls to ligature-resistant toilet bowls (flush to the back wall), with an anticipated date of completion for the entire unit being February 28, 2019. The current flush valves/tanks on the MHU meet the current design guidelines as ligature resistant, however the flush valves/tanks will eventually be replaced as well, a) As toilet bowls are replaced, the need for an assigned sitter to the room will be re-evaluated. The Immediate Response for Hall B shower was, 1) Provide one to one staffing by utilizing charge nurses for all patients taking showers, regardless of the patient's suicide risk status. The shower door is to remain ajar while the patient is in the shower, 2) Replace shower valve (handle to ligature-resistant handle), with anticipated date of completion no later than February 10, 2019. At the time the ligature-resistant handle is installed, the one to one for all patients will be discontinued.

The IMMEDIATE JEOPARDY was abated on 2/1/19 at 12:20 p.m. Administrative Staff B, C, and D were present in the Conference room when the IJ was abated.

Online review of The Joint Commission (hospital accreditation agency) article titled "Quality and Safety," subtitled, "November 2017 Perspectives Preview: Special Report: Suicide Prevention in Health Care Settings," further subtitled, "Recommendations Regarding Environmental Hazards for Providers and Surveyors" revealed suicide is now the tenth leading cause of death in the United States. The article indicated the recommendations were intended to provide guidance on what constitutes adequate safeguards to prevent suicide;
"Recommendations for Inpatient Psychiatric Units in both psychiatric hospitals and general/acute care settings, must be ligature-resistant in the following areas: ...Patient bathrooms..." The Joint Commission defined ligature-resistant as, "without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life."
(https://www.jointcommission.org/issues/article.aspx?Article=GtNpk0ErgGF%2B7J9WOTTkXANZSEPXa1%2BKH0%2F4kGHCiio%3D)

During an interview on 1/24/19 at 12:20 p.m., Administrative Staff A stated the facility did not have a policy and procedure regarding ligature risks in the BHU.

Review of facility policy titled, "Mentally disturbed and Suicide/Violence Risk Assessment," subtitled, "Policy: Compliance - Key Elements," further subtitled, "J. Suicide or Homicide Precautions: Behavioral Health" (revised 5/16/17) indicated, "8. Document appropriate observations on the.... Suicide Intent/Ideation Individualized Plan of Care...Record on Patient Care Treatment Record when the physician was notified of patient's suicide/intent/ideation."

2.a.) During an interview and concurrent review of the facility's Performance Improvement binder on 1/25/19 at 11 a.m., Physician GG confirmed he was the current in-coming Chair of the Performance Improvement Committee. When asked if he attended any Performance Improvement Committee meetings in 2018, Physician GG stated, "No." When asked if he was aware of the December 20, 2017 or the July 19, 2018 Suicide/Self-Harm Assessments, Physician GG stated, "No." When asked if he was aware there were no Performance Improvement projects related to the assessments, Physician GG stated, "No."

During an interview and concurrent review of the facility's QAPI binder on 1/29/19 at 2:30 p.m., Physician HH confirmed he was the 2018 Chair of the Performance Improvement Committee. When asked if he was aware of the December 20, 2017 or the July 19, 2018 Suicide/Self-Harm Assessments and the findings that the patient bathroom doors on the Behavior Health Unit (BHU) were a "high" ligature risk, Physician HH stated he did not recall that specifically. He stated Performance Improvement projects are proposed by facility department managers and Administrative Staff B.

During an interview and concurrent PI binder review on 1/31/19 at 10 a.m., Administrative Staff B was asked why there were no Performance Improvement (PI) projects related to the two ligature risk assessments. She stated the assessments were handled through the Safety Committee which does not report to the PI Committee, but rather to the Governing Board.

Review of the 2018 "Performance Improvement Reporting Schedule" in the Performance Improvement (QAPI) binder found only one mention of the "Mental Health Unit" for the August 21, 2018 meeting. The topic of discussion was a "Plan-Do-Study-Act" regarding an improper legal hold. There was no mention of the anti-ligature risk assessments and the mitigation efforts.

Review of the 2018 "Performance Improvement Project Prioritization Grid" in the Performance Improvement binder found no mention of projects for the Behavioral Health Unit. Three projects were listed for the Senior Behavioral Health Unit related to "Inpatient Psychiatric Measures," "Tobacco Measures," and "Substance Abuse Measures." There was no mention of the anti-ligature risk assessments and the mitigation efforts.

2.b.) During an interview and concurrent PI binder review on 1/31/19 at 10:20 a.m., Administrative Staff B stated construction projects for the physical environment are not managed through the Performance Improvement (QAPI) Committee.

Review of the 2018 "Performance Improvement Reporting Schedule" in the Performance Improvement binder found no mention of the facility's Physical Environment.

Review of the 2018 "Performance Improvement Project Prioritization Grid" in the Performance Improvement binder found no mention of projects for the facility's Physical Environment.

Review of the policy titled, "Quality Assurance/Performance Improvement Plan 2018-2019," revised 12/3/18, indicated: "As part of its quality assessment and performance improvement program, the organization must conduct performance improvement projects. a. The number and scope of distinct improvement projects conducted annually shall be proportional to the scope and complexity of the hospital's services and operations. b. The organization shall document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. c. While the organization is not required to participate in a CMS Quality Improvement Organization (QIO) cooperative project, its own projects shall be of comparable effort."