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.

LIFESTREAM BEHAVIORAL CENTER 2020 TALLY RD LEESBURG, FL 34748 Feb. 1, 2020
VIOLATION: QAPI Tag No: A0263
Based on interviews, medical record reviews, observations, and policy and procedure review, the hospital failed to ensure the implementation and efficacy of an ongoing data-driven quality assessment and performance improvement program for patients receiving care in a safe setting for physician ordered precautions for two patients who were successful in committing suicide by hanging, while under physicians' orders for continuous visual observation, Patients #1 and #2. The actions taken by the facility did not remove the immediacy for 3 of 7 total patients with physician ordered special precautions for continuous visual observations or 1:1, Patients #3, #4, and #6. These systemic failures constitute an immediate jeopardy situation. Refer to A043 Governing Body, A115 Patient Rights, A144 Patient Rights: Safe Care Setting, and A283 Quality Improvement Activities.

On February 4, 2020 at 11:33 AM, the Senior Vice Present Acute Care Services was informed of the ongoing IJ situation which began on June, 05, 2019. The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, observations, plan of correction review, and policy and procedure review the hospital failed to ensure an effective and acceptable plan of correction was developed or fully implemented, and failed to measure the success, track the performance, to ensure the actions taken were sustained for a patient who was measure its success related to data collection identifying opportunities for improvement and changes that will lead to improvement for two sentinel events for physician ordered precautions for two patients who were successful in committing suicide by hanging, while under physicians' orders for continuous visual observation, Patients #1 and #2. The actions taken by the facility did not remove the immediacy for 3 of 7 total patients with physician ordered special precautions for continuous visual observations or 1:1, Patients #3, #4, and #6.

The findings included:

Review of the LifeStream Psychiatric Hospital Sentinel Event Plan reviewed 01/09/2020 reads: Purpose: This plan outline the procedure for identifying, reporting and responding to the occurrence of a sentinel event at LifeStream Psychiatric Hospital. This plan ensures thorough and comprehensive analysis and evaluation of patient-related adverse vents in conjunction with quality improvement activities of the Medical Staff and clinical departments. Rationale: LifeStream Psychiatric Hospital fully endorses and supports the importance of performance improvement in every aspect of providing healthcare services. The occurrence of a serious and adverse event at this organization shall be quickly and thoroughly investigated and analyzed so as to identify and understand the causes (s) in variation in performance and promptly implement the necessary changes to reduce the probability of reoccurrence of such events in the future. Appropriate response includes a thorough and credible root cause analysis, implementation of improvements to reduce risk and monitoring of the effectiveness of those improvement. 6. The Director of Quality Management will be responsible for conducting the root cause analysis and for developing an action plan, which includes risk reduction strategies, as well as holding all meetings and investigations associated with the sentinel event. The action plan shall address assigned responsibility for implementation, oversight, pilot testing as appropriate, timelines and strategies for measure the effectiveness of the actions.

Review of the Quality Improvement Meeting Minutes dated 11/27/2019 there was no documentation related to the Sentinel Event that occurred in 06/2019 for Patient #2 who successfully committed suicide by hanging. There was no documentation regarding the facility Risk Assessment, or the findings of the architectural firm hired by the facility for recommendation related to ligature risks.

Review of the Hospital Quality Improvement Meeting dated 12/10/2019 under the Section titled, "Discussion Items" read: Unit Walk Through: Unlocked bathrooms - Improvement noted and continuous monitoring to ensure compliance. There was no documentation related to the Sentinel Event that occurred in 06/2019 for Patient #2 who successfully committed suicide by hanging. There was no documentation regarding the facility Risk Assessment, or the findings of the architectural firm hired by the facility for recommendation related to ligature risks.

Review of the Hospital Quality Improvement Meeting dated 12/18/2019 revealed there was no documentation related to the Sentinel Event that occurred on 12/15/2019 for Patient #1's successful suicide by hanging. There was no documentation regarding the facility Risk Assessment, or the findings of the architectural firm hired by the facility for recommendation related to ligature risks.

Review of the Hospital Quality Improvement Meeting dated 01/14/2020 revealed there was no documentation of Sentinel Event that occurred on 12/15/2019 for Patient #1's successful suicide by hanging. It was not listed on the table of contents. There was no documentation regarding the facility Risk Assessment, or the findings of the architectural firm hired by the facility for recommendation related to ligature risks.

Review of the Corrective Action Plan: read: O1. Risk Reduction Strategy: Enforcing Policy and Procedures on locking bathroom doors and monitoring of patients whenever a bathroom is in use. Using centralized bathroom on the male unit during first and second shifts to eliminate the opening of bedroom and bathroom doors for patients due to the size of the unit. Initiate one staff to continuously walk units and check bathrooms during first and second shift. Staff is to notify the Nursing Supervisor when a lack of compliance is found. Responsible Party: DON. Time Frame: 12/20/2019. Monitoring: The DON and Nursing supervisor are reviewing SP sheets daily for compliance. Management Team is walking assigned units to also ensure compliance. Effective 1/2/2020. The DON, ADON or Hospital RM will review videos and/or real time checks daily of 4 patients on SPs or 1:1 to see that they are being monitored appropriately. The DON, ADON and/or RM will perform this function daily for four weeks. After that time, the monitoring will continue 3 times a week for the next four weeks and then to twice a week continually. This is to include agency personnel as well as LifeStream staff. Progressive disciplinary action for LifeStream staff that is not compliant. Agency staff will be given two warnings before being asked not to return. If deviations from the procedure are found, monitoring will be moved back to daily reviews for four weeks continuing as outline above. O2. Risk Reduction Strategy: Actively explore separating the unit in to two distinct areas. We have contacted a software provider and are exploring the use of digital room monitoring devices to further ensure face to face monitoring will be provided per procedure. Visit Renaissance Behavioral Health and Mental Health Resource Center to review environmental safety improvements made in those inpatient facilities. Responsible Party, DON, ADON, RM, Hospital Administrator. Time Frame: February 14, 2020. Measure of Effectiveness (How will we know if this works?) was left BLANK. O3. Risk Reduction Strategy: Training staff on how each precaution is provided and documented correctly. Having color coded precautions on all name assignment boards that also matches precautions on the patients' bracelets. Each staff member will carry a laminated card that will reflect the color and meaning f the color-coded risk categories. Responsible Party: DON, ADON. Time Frame: 02/07/2020. Measure of Effectiveness: 10/10 staff can verbalize color-coded bracelet meaning, precaution procedures and documentation requirements upon random inquiry from DON, Nursing Supervisor or Management Team member. O4. Risk Reduction Strategy: Explore the use of paper gowns for patients. Explore changing Q15 checks to those patients on SPs and 1:1. Assigning an Access Center nurse. This nurse will be responsible for gathering information to speak to providers and get admission orders. This nurse will also identify the severity of patients need to for special precautions and take the patients to units to communicate with unit staff for nurse to nurse handoff. Responsible Party: DON, RM, Sr. (Senior) VP (Vice President) of Acute Care Service. Time Frame: 01/17/2020. Measure of Effectiveness (How will we know if this works?) was left BLANK. O5. Risk Reduction Strategy: Explore changing nursing staff to 12-hour shifts. Responsible Party: DON, ADON, RM, Sr. VP of Acute Care Services. Time Frame: 02/21/2020. Having staff work 12 hour shift will reduce the chaos of shift change being three times a day, to twice a day, to twice a day. Staff will also work 3, 12 hour days on the same unit improving continuity of care.

Review of the Quality Improvement Operational Procedure last revised March, 2017 read: A. Purpose: To establish a structure for the formation, conduct, and activities of Continuous Quality Improvement (CQI) teams in order to promote such teams within the organization, ensure that their activities are guided by CQI principles, and facilitate the integration of their findings into the Center's processes. B. Procedure: IV. Team Process: In conduiting its work the CQI Team will follow a 5-step sequence based on the Plan-Do-Check-Act (PDCA) model of quality improvement. The Team will: Determine the desired improvement. Identify customers and their requirements. Analyze the current process. Design the new process (or modify an existing process) and implement changes. Evaluate the results, and make further changes as necessary.

Patient # 1:

Review of Patient #1's medical record revealed the Patient was transported to the facility by law enforcement on 12/15/2019 at 6:00 AM. The general information read: Patient #1 is suicidal and advised his mother that he wanted to kill himself. Patient #1 further stated to his mother that he was going to hang himself. Review of diagnosis included Schizophrenia with a witness attempted hanging at home by his mother.

Review of the Bio-psychosocial Intake Assessment completed on 12/15/2019 with a start time of 8:19 AM and an end time of 9:49 AM revealed: Summary /Recommendation: Patient #1 reported that he is currently suicidal and while in the access center he cut himself with the UDS [Urine Drug Screen] cup on the wrist, indicating an extreme risk of harm to himself with severe impairment.

Review of the physician's orders dated 12/15/2019 at 8:30 AM read suicide precautions x 24 hours, Constant Visual Observation.

Review of the incident report for 12/15/2019 at 8:00 AM read: Sunday morining 12/15/2019 Patient # 1presented involuntarily and was on a Baker Act initiatated by Law Enforcement. Evaluator accepted pattient and checked patient # 1 into the access center. Evaluator started a security check on consumer by checking pockets, shoes, socks and wanding consumerup and down and front and back. The evaluator handed patient # 1paperwork and a UDS cup, gave belongings to office. Approached patient # 1 and asked if he needed help with paperwork. Patient# 1 responded no, okay. I retrived his paperwork and went to do vitals and observed on his left arm with a long mark. He handed me the UDS cup underneath his shirt. I made the other staff memeber aware of what had taken place and asked who do I call. the other staff member stated to call the nursing supervisor. The nursing supervisor came to the access unit and checked patient# 1 arm, gave me a camera to take picture of his arm and the cup. No physcian notification wasd completed with this incident per the evaluator. patient # 1 transported to the Male Psychiatyric Care Unit between 10:15 AM and 10:30 AM. On 12/15/2019 at 6:20 PM, a medical emergency was called, to Male PSU room 206 sucide geature. when i entered room 206 and saw Patient # 1 hanging with a noose around his neck from the bathroom door. I pulled him down and started CPR( Cardio-Pulmonary Resucitation) while calling to staff and physician. ( Patient # 1 did not survive).

Review of the Special Precaution sheets for suicide precautions and Continuous Visual Observation (CVO) were reviewed and revealed they were initialed from 10:30 AM until 7:00 PM. Starting at 3:00 PM until 7:00 PM the Special Precaution sheets were initialed by the attending Behavioral Technician for the period of time as viewed on the video as documented below:

Video Timeline of events from 3:01 PM to 6:56 PM for the date of the incident, 12/15/2019 showed:
3:01 PM Patient #1 enters his room and exits at 3:03 PM.
3:13 PM the Licensed Practical Nurse (LPN) enters the room for room check.
3:45 PM: Patient #1 enters and exits room his room.
4:23 PM: Patient #1 is in and out of his room twice in two minutes
4:28 PM: Patient #1 was at the nurse's station and appears to speak to a staff member, the staff member then gets up and enters the patient's room and exits as Patient #1 then enters next and exits.
4:30 PM: Patient #1 enters and seconds later closes the bedroom door leaving it cracked.
5:51 PM: The Behavioral Technician (BT) opens the door to check for patients to go for dinner. Patient #1 is not observed exiting room.
6:22 PM: Patient #1's roommate exits the room and goes to nurses' station.
6:27 PM: Patient #1's roommate goes back in and sits with a towel in the room.
6:28 PM: Patient #1's roommate returns back to the nurse's station.
6:29 PM: Nurse enters the room and finds Patient #1 in the bathroom
6:38 PM: EMS (Emergency Medical Services) arrived.
6:56 PM: Patient #1 left with EMS.

Review of the medical record for Patient #2 revealed he was admitted to the facility on [DATE] with diagnosis to include Schizophrenia disorder, degenerative disk disease in the cervical spine, and bipolar disease.

Review of the Intake assessment dated [DATE] at 10:04 PM provided documentation dated 05/19/2019 by a physician at another facility which read: Exacerbation of schizophrenia, acute auditory hallucinations, intentional prescription medication overdose, and acute agitation. Patient was brought to the ED after he called police for help. [Patient #2's name] states hearing women's voice in his head that is too much. Admits to taking an intentional overdose of his prescription medications to make voices stop. Patient told the police he wanted to see if he overdosed that hearing voices in his head and are trying to kill him.

Review of the physician's orders dated 05/30/2019 at 1:15 PM read place on 1:1 observation, no gown, no sheets and no pillowcase.

Patient # 2:

Review of the Nurses' Inpatient Rounds notes for Patient #2 dated 05/30/2019 at 2:37 PM read: Patient #2 attempted to hang himself earlier "because of the pain." He never lost consciousness. Was transferred to ER (emergency room ) for excruciating pain not relieved with medications.

Review of the receiving hospital notes dated 05/30/2019 read: Chief Complaint: Back pain, patient is schizophrenic and admits hearing voices this morning that told him he should attempt suicide to get the pain to stop.

Review of the Nurses' Inpatient Rounds notes dated 05/31/2019 read at 8:09 AM read: Patient #2 reports he is in physical pain therefore he is feeling suicidal due to not tolerating the pain,

Review of the physician's notes revealed dated 5/31/2019 read: Continues to complain of back pain, sent to hospital and returned with medical clearance, attempted to hang himself with shirt yesterday, labile delusional up all night the night before. Dated 06/04/2019 0/10 depression/anxiety, and complaint of back pain.

Review of the Special Treatment checklist revealed 1:1 observation was discontinued on 6/1/2019 as documented by the attending nurse. Patient # 2 was receiving every 15-minute checks as documented on the Special Treatment checklist sheet.

Review of the physician's orders for the period of 05/30/2019 to 06/5/2019 revealed there was no order written to discontinue 1:1 observation.

Review of the video for Patient # 2 of the incident that occurred on 06/05/2019 revealed the Behavioral Technician (BT) did not provide every 15-minute checks, no 1:1 was conducted. Patient #2 was not observed after 05:32 AM due to disruptions on the clinical unit, but documented the observations were being conducted. During change of shift occurring at 7:00 AM the arriving technician began rounds and discovered the consumer in Room 211 hanging from his gown.

Review of the investigation read: Patient was found hanging in his room on the morning of 6/5/2019. He had tied his grown around his neck and secured it to a hinge of the bathroom door. Staff responded and began CPR until EMS arrived. [Patient #2 did not survive].

Review of the Special Treatment Sheets revealed Patient # 2 was to be on 1:1 on 06/05/2019. The Special Treatment Sheet was initialed every 15 minutes indicating the patient was observed every 15 minutes, not 1:1.

Patient # 4:

During a tour of the Male Psychiatric Care Unit (PCU) on 01/29/2020 at 4:36 AM shows there were 18 patients with one patient on 1:1 observation, one patient on CVO, two patients were on suicide precautions. The 1:1 observation for the Patient identified as #4, the nurse was in the nurse's station when the surveyor entered the unit and proceeded to sit outside the patient's door, approximately 10 - 20 feet from the patient during my tour, with her back toward the patient's room door. Review of the 15-minute check sheets were completed; all sheets were filled out up to 04:30 AM. The observation continued until 5:28 AM and showed the nurse conducting the 1:1 documented on the 15-minute check sheet that the ordered 1:1 was being conducted per the facility procedures.


Review of the physician orders initiated on 1/28/2020 at 1:15 PM read: Suicide precautions (SP) x 24 hours, 1:1 observation x 24 hours. Finger foods, no silverware x 30 days.

Review of the video for Patient #4 was conducted with the Facility RM (Risk Manager) on 01/29/2020 at 3:15 PM and showed:

12:08 AM-12:09 AM staff was not in the doorway or at patient's bedside. Staff was observed walking away from the patients' room. Leaving the patient unattended.
12:12 AM-12:15 AM staff was not in the doorway or at bedside. Staff was observed walking away from room. Leaving patient unattended.
12:24-12:25 AM staff was observed walking away from the room. Leaving the patient unattended.
12:44 AM-12:48 AM: staff was observed walking away leaving patient unattended.
12:53 AM-12:56 AM staff left the patient unattended. Staff was observed walking away from the room.
12:57-1:07 AM staff observed walking away from room, leaving patient unattended.
1:08 AM Staff walked away briefly < 1 minute
1:13 AM-1:14 AM staff walked away leaving patient unattended,
1:16 AM staff walk away briefly < 1 minute.
1:32 AM-1:33 AM staff walked away leaving patient unattended
1:43 AM staff briefly walked away
1:57 - 2:01 AM staff walked away leaving the patient unattended.
2:12 AM staff briefly walk away < 1 minute
2:15-2:22 AM staff walked away leaving the patient unattended.
2:51 AM - 2:52 AM Staff walked away from room
2:57 AM staff walked away briefly <1 minute
3:02 AM Staff walked away from room briefly < 1 minute
3:03-304 AM staff walked away patient was unattended.
3:06 AM staff walked away briefly < 1 minute
3:10 AM - 3:12 AM staff walked away leaving the patient unattended.
Starting at 3:19 AM the staff member placed her chair to the right side of the door to room 206 facing away from the patient's room, facing the nurse's station, not observing the patient on the required 1:1 observation until 4:34 AM when entry was made on the unit at 4:36 AM on 01/29/2020 and observed the staff assigned to the 1:1 in the nurse's station.

During an interview on 1/29/2020 at 3:40 PM, the Facility Risk Manager (RM) stated, "Well, people have to go to the bathroom, but they should be getting staff to cover the patient. I guess they shouldn't leave for even a minute. This is not providing 1:1 or even CVO when staff leave the doorway of the room when the patient is sleeping. They should get someone to cover them and be at the doorway. It is not safe for staff to be in the rooms with patients that is why they can sit or stand in the door of the room. This staff member is sitting outside the room not even facing the patient and that is not our policy and the patient is not being observed as a 1:1 or even a CVO, but she did do every 15-minute checks."

During an interview on 1/31/2020 at 3:05 PM the DON stated, "This is unacceptable for the patient and does not meet the expectation of 1:1 observation. Staff are to be within arm's reach of the patient at all times, at night we don't feel staff should be in the patients room, so they are to sit in the doorway continually, if they leave they must get someone else to cover the time, even if it is briefly. This staff member should have the special precaution sheet with her and not get up to sign it. It was disturbing enough when she was leaving that frequently, but it was totally unacceptable when she positioned her chair to the side and wasn't even facing the room. All I can say is we did not do the physician ordered 1:1 observation from 3:11 AM until 4:34 AM when you entered the unit. We did put this patient at risk for that entire time when she was sitting on the side of the doorway and facing away from the patient. We did not follow physician orders and we did not follow our policies for patient safety. I think we are in real trouble because this is a potential for harm. I really thought we were doing so much better than this and maybe it's a good thing this happened when you came so we can prevent any further patients' deaths. I'm just sorry it takes this. We are failing our patients, failing to provide a safe environment. We aren't following doctors' orders, checking charts and verifying the correct precautions are being done and not doing CVO or 1:1 observations when administration is not here." A request was made for the documentation of the videos that had been reviewed for patients with orders of CVO, 1:1, and the viewing of agency nurses. No documentation was provided.

During an interview on 02/01/2020 at 11:38 AM with the DON documentation was requested for the viewing of patients for observation under CVO, 1:1, and the agency nurses for compliance with the hospital's policies and procedures. The DON stated, "We don't have any documentation. We did not do video reviews."

During an interview on 1/31/2020 at 2:55 PM with the ADON stated, "Based on this video, we did not provide an adequate 1:1 observation of this patient. Staff need to be within arm's reach of patients when they are 1:1 observation. At night they need to be in the patient's doorway when the patient is asleep. We did not follow the physician order for 1:1 observation. It is my expectation that if staff need to leave the doorway that they get staff to cover them. This patient did not receive 1:1 observation continuously from 3:11 AM until you entered the unit at 4:34 AM. It is not acceptable practice. We expect and need to do much better than this. I do not think that we provided a safe environment for this patient based on what I have seen."

During an interview with Staff M, RN (Registered Nurse) on 1/29/2020 at 04:40 AM she stated, "One on one [1:1] means that you must always be within reach of the patient even when they are sleeping. The staff doing 1:1 was not within arm's reach when you arrived, and she should have been. They had us do the color codes and have pictures of the patients so if we don't know them, we can easily identify them. Honestly, not everyone has a photograph and I don't know who is responsible for making sure they are in the book with the sheets."

During an interview on 01/29/2020 at 4:50 AM, with Staff N, LPN (Licensed Practical Nurse) assigned 1:1 observation for Patient #4, stated, "I am an LPN and am assigned to the 1:1 observation of the patient. I was at the nurse's station when you came in and am supposed to be within reach of the patient. I was before you came in, I was just signing his sheet. I am supposed to be in view of the patient that's why I am outside of the room. When the patient is awake, we are at arm's length when they sleep, we can be in the doorway, visualizing them always. We cannot leave the 1:1 observation patient, if we do someone else must cover them. I cannot leave to go to the bathroom without someone sitting in the doorway. We still initial the sheet and those are my initials on the special precaution's sheets. It shows I was doing the ordered observation."

Patient # 6:

Review of the medical record for Patient #6 revealed the patient was admitted on [DATE] at 1:36 AM to the access center under a Baker Act initiated by a physician at a hospital's ED (Emergency Department) on 12/2/2019 at 7:00 PM stating that patient # 6 had suicidal thoughts and planned to throw self in front of a moving vehicle. Patient # 6 was transported by an officer from [name of the County Sheriff Office] on 12/10/2019 at 11:10 PM. [AGE] with diagnosis to include Bipolar Disorder.

Review of the physician order dated 1/16/2020 at 08:50 AM CVO's. Further review revealed there was no order to discontinue CVO.

A review of the special treatment checklist for the period of 01/16/2020 at 08:50 AM until 01/25/2020 the patient was not on CVO according to the special treatment checklist; only 15-minute checks were documented as having been conducted. The CVO box was not checked to indicate the patient was to be on continuous visual observation. Dated 01/27/2020 from 10:15 PM to 11:00 PM there was no documentation of the patient having even been visualized.

During an interview with the DON on 01/31/2020 at 2:10 PM she stated, "I was not aware that [Patient #6's name] did not have the correct precautions implemented from 01/16/2020 until 01/25/2020. This is again eight days that we did not follow physician orders for the patient. Again, I'm not sure why we didn't do what we are supposed to, and I was not aware of this. No, our plan of correction is obviously not working. This is truly eye opening I thought we were doing a good job at following this plan, we talk about it weekly. I should be doing more than I am. I guess I counted on the fact that the walking lead tech was verifying the orders as well, and the nurses should be verifying these during the chart checks. Maybe they are just signing that they did them."

Patient # 3:

During a tour of the Female PCU (Female Psychiatric Care Unit) on 01/29/2020 at 5:30 AM shows there are eight patients, five patients are identified as suicide precautions, three are on CVO, and one patient is ordered to be on 1:1 observation. Patient #3 was ordered for CVO. There was no staff observed in the common area or the hallway outside of the common area room. A review of the 15-minute check sheets indicated they were filled out to the appropriate time and were not prefilled but indicated the required CVO observation was being conducted per physician order and facility procedures.

Review of the medical record for Patient #3 revealed an admission date of [DATE] via Baker Act and escorted by law enforcement. with diagnosis to include brief psychotic disorder, multiple personality disorder, and Schizophrenia.
Review of the physician's order dated 12/11/2019 revealed SP (Suicide Precautions) x 24 hours, CVO and VAP (Violent Assault Precaution) were ordered. Dated 12/12/2019 the physician ordered SP x 24 hours and VAP. CVO was not discontinued. On 12/16/2019 SP x 24 Hours and CVO was reordered. Dated 1/29/2020 at 7:25 AM CVO/SP due to hanging gown on shower head/self-harm were ordered.

A review of the Special precaution sheets that were available in the chart from 01/03/2020 - 1/14/2020 indicates the patient was on Suicide, VAP (Violent Assault Precautions), elopement and CVO (Continuous Visual Observation).

Staring on 1/15/2020 until 1/24/2020 the patient's Special Treatment Sheets showed the patient was being observed for VAP only by the checking of the VAP box on the sheets.

During an interview on 1/29/2020 at 5:45 AM, with Staff F, an LPN (Agency Nurse Female Unit) stated, "I am an agency nurse and have worked here for about 2 years now. When patients are on special precautions, they are on 1:1 Observation staff must always be within arm's reach of them, at night because it is not safe to be alone with patients, we have a chair and sit in the doorway. We should not leave the patient even to get a drink or use the restroom without someone there with the patient. When patients are on CVO they are always in our vision, that is why they get rooms closest to the nurse's station so we can see them from here. Patient #3 is on CVO, she is in the dayroom, no I suppose she is not on CVO if we are not in sight of her. She has times when it is easier to let her sleep there because she doesn't like to lay flat so many times, she will sleep in there, it keeps her less agitated. We are constantly understaffed, especially on evenings and nights on weekends. The nursing supervisors take multiple units and do the access center. As an agency nurse I am not allowed to help with any type of a patient hold, so when we have an emergency that we cannot deescalate verbally, the staff are placed in a very dangerous situation. The nursing supervisors can't respond when they have other units to cover, it places all patients and staff at risk. It is dangerous for patients and staff when we don't have staff. I have worked with no behavioral technicians too. I have talked to the administrator and director of nursing, but nothing is changing its just getting worse. They are hiring people, but they leave quickly when their licenses are at risk. I refuse to take any more than one unit at a time, they have asked me to do two, but I won't. When that happens, they have the supervisors take the units. They also cover the access units and do the assessments, it's not safe. We did not get any training on these new color codes, they just appeared, and we were told to do them. They don't offer agency nurses any additional training. These patients are not safe when we have no staff. I'm sorry but the administrator understands that we are not safe here. I'm glad you all are here on nights it's about time. You all come on days and everything is perfect, but the problems have been occurring on evenings weekends and nights.

During an interview on 01/29/2019 at 6 :00 AM, with BT Staff F (female unit) stated, "I am a fulltime staff member, its almost always short staffed on the weekends on Friday and Saturday nights. They have the nursing supervisors taking multiple units and they are in the access unit too. It seems to have gotten worse lately. I have complained to the Director of Nursing, the assistant director, all the supervisors and the administrator. Nothing has changed, the director of nursing has never worked a shift that I know of. It has become unsafe for the staff and the patients. You all need to check out the staffing sheets. I'm glad you all are here at night to see this. 1:1 observation means we should stay at arm's length of the patients at night we stay in the patient's doorway because it's a safety risk for staff to be alone in a patient's room, continuous visual observation means a staff is always in view of the patient. I have 3 patients on CVO, one of them is in the dayroom, she sleeps in there because she can't lay in bed, she is more comfortable sitting up. That is at the end of the hall. I still do my every 15-minute checks, but no I guess that is not CVO if she is in there and I can't see her. I have initialed the special precaution sheets tonight and they do say that she is in CVO. But they sent a behavioral tech home at 3:00 AM because we are overstaffed for the number of patients we have.

Review of the environmental Risk assessment dated [DATE] revealed on Page 6 - 6. Sink piping is not exposed and accessible to consumer, this can be used as an anchor for hanging. Scoring = 0 Never. 1 Low. 2 Moderate. 3 High. Probability of Failure - 3. Consumer Impact - 3. System Preparedness. Total Risk Score - Total of Probability & Severity Scores - 9. Provide a brief summary of actions taken and mitigations to reduce either the probability and/or severity of failure of the applicable process step or deviation from standard of care. Facility addressing - completing 1 room at a time. 7. Toilet piping is not exposed and accessible to consumer, this can be used as an anchor for hanging; to include toilet seats. Scoring = 0 Never. 1 Low. 2 Moderate. 3 High. Probability of Failure - 3. Consumer Impact - 3. System Preparedness - 3. Total Risk Score - Total of Probability & Severity Scores = 9. Bathroom doors locked when not in use staff monitor when consumer using bathroom acute suicidal consumers on 1:1 monitoring. Page 2 - 8. Grab rails are closed in and still permits consumers to grasp as needed, but not allow for an anchor for hanging. (Meet UFSA standards). Probability of Failure - 3. Consumer Impact - 3. System Preparedness - 3. Total Risk Score - Total of Probability & Severity Scores = 9. Facility addressing - completing 1 room at a time. 9. Door latching hardware is designed and installed to prevent it from being used a
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, observations, and medical record review, the hospital failed to honor patient rights for care in a safe setting after two patients were successful in committing suicide by hanging, while under physicians' orders for continuous visual observation, Patients #1 and #2, for 3 of 7 total patients who were ordered Continuous Visual Observation or 1:1, Patients #3, #4, and #6. The hospital staff failed to conduct the physician ordered safety precautions for Patients #3 for continuous visual observations, Patient #4 for 1:1 observation, and Patient #6 for continuous visual observations. These systemic failures constitute an immediate jeopardy situation. Refer to A144 Patient Rights: Care in Safe Setting.

On February 4, 2020 at 11:33 AM, the Senior Vice President Acute Care Services was informed of the ongoing IJ situation which began on June 05, 2019.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, observations, and policy and procedure review, the hospital failed to ensure patients received care in a safe setting for physician ordered precautions for two patients who were successful in committing suicide by hanging, while under physicians' orders for continuous visual observation, Patients #1 and #2. The actions taken by the facility did not remove the immediacy for 3 of 7 total patients with physician ordered special precautions for continuous visual observations or 1:1, Patients #3, #4, and #6.

Findings:

Patient # 1:

Review of Patient #1's medical record revealed the Patient was transported to the facility by law enforcement on 12/15/2019 at 6:00 AM. The general information read:
Patient #1 is suicidal and advised his mother that he wanted to kill himself. Patient #1 further stated to his mother that he was going to hang himself. Patient #1 went into his mother's bedroom with a belt around his neck, asking her to kill him. Mother was able to remove the belt from around his neck and he stated that if she didn't do it, he would. Review of diagnosis included Schizophrenia with a witness attempted hanging at home by his mother.

Review of the Bio-psychosocial Intake Assessment completed on 12/15/2019 with a start time of 8:19 AM and an end time of 9:49 AM revealed: Summary /Recommendation: Patient #1 reported that he is currently suicidal and while in the access center he cut himself with the UDS [Urine Drug Screen] cup on the wrist, indicating an extreme risk of harm to himself with severe impairment. Patient #1 reported frequent use of molly, although he did not provide a UDS sample. Patient #1 reported that he is currently homeless and has minimal support in his environment. Patient #1 appeared moderately responsive to treatment with limited engagement.

Review of the physician's orders dated 12/15/2019 at 8:30 AM read suicide precautions times 24 hours, Constant Visual Observation.

Review of the incident report for 12/15/2019 at 08:00 AM read: Sunday Morning 12/15/2019, Patient #1 was presented involuntarily on a Baker Act that was initiated by the Law enforcement. Evaluator accepted consumer and checked him into the access center. Evaluator started security check on consumer by checking pockets, shoes, socks wanding consumer up and down front and back. I handed consumer paperwork and UDS cup, gave consumer belongings to office. Approached consumer asked did he need help with paperwork. Consumer responded I can do this, I said ok. I retrieved his paperwork and went to do his vitals and observed his arm (left) with a long marking, asked how that was done. He handed me the UDS cup from under his shirt. I made [co-worker's name] aware of what expired and asked who I call, and she called the Nursing Supervisor [Nursing Supervisor's name], she came to access center and looked at wound and attended to wound. [Co-worker's name] gave me camera to take picture of consumer and his wound, then UDS cup. [No physician notification was completed with this incident per the author.] Patient transported to the Psychiatric Care Unit (PCU) Male unit between 10:15 AM and 10:30 AM.

On 12/15/2019 at 6:20 PM Medical Emergency, PCU (Psychiactric Care Unit) Male Room 206 suicide gesture. At approximately 6:20 PM I entered Room 206 and saw Patient #1 hanging with a noose around his neck from the bathroom door. I pulled him down to the floor and started CPR [Cardio- Pulmonary Resuscitation] while calling to staff and Physician. (The patient did not survive).

Review of the incident report dated 12/15/2019 at approximately 6:20 PM reads "I entered Room 206 and saw Patient #1 hanging with a noose around his neck from the bathroom door. I pulled him down to the floor and started CPR while call to staff for a Dr. Heart [facility medical code call for emergency medical condition]. Staff and the supervisor assisted with AED [Automatic External Defibrillator], oxygen and switching out CPR until EMS [Emergency Medical Services] arrived. patient # 1 returned from dinner at approximately 6:10 PM. At 6:15 PM showers were to start at that time and shower equipment was given. Patient #1's roommate was also in the room when Patient #1 was taken down from door. Addendum: Consumer had a gown and a sheet around his neck. Patient went to the floor after the door was opened with assistance of Behavioral Tech. Incident report dated 12/15/2019 read 6:20 PM Medical Emergency, PCU Male Room 206 suicide gesture, external agency involved EMS, physician notified 12/15/2019 at 6:45 PM.

Review of the Special Precaution sheets for suicide precautions and Continuous Visual Observation (CVO) were reviewed and revealed they were initialed from 10:30 AM until 7:00 PM. Starting at 3:00 PM until 7:00 PM the Special Precaution sheets were initialed by the attending Behavioral Technician for the period of time as viewed on the video as documented below:

Video Timeline of events from 3:01 PM to 6:56 PM for the date of the incident, 12/15/2019 showed:
3:01 PM Patient #1 enters his room and exits at 3:03 PM.
3:13 PM the Licensed Practical Nurse (LPN) enters the room for room check.
3:45 PM: Patient #1 enters and exits room his room.
4:23 PM: Patient #1 is in and out of his room twice in two minutes
4:28 PM: Patient #1 was at the nurse's station and appears to speak to a staff member, the staff member then gets up and enters the patient's room and exits as Patient #1 then enters next and exits.
4:30 PM: Patient #1 enters and seconds later closes the bedroom door leaving it cracked.
5:51 PM: The Behavioral Technician (BT) opens the door to check for patients to go for dinner. Patient #1 is not observed exiting room.
6:22 PM: Patient #1's roommate exits the room and goes to nurses' station.
6:27 PM: Patient #1's roommate goes back in and sits with a towel in the room.
6:28 PM: Patient #1's roommate returns back to the nurse's station.
6:29 PM: Nurse enters the room and finds Patient #1 in the bathroom
6:38 PM: EMS (Emergency Medical Services) arrived.
6:56 PM: Patient #1 left with EMS.

Patient # 2:

Review of the medical record for Patient #2 revealed he was admitted to the facility on [DATE] with diagnosis to include Schizophrenia disorder, degenerative disk disease in the cervical spine, and bipolar disease.

Review of the Intake assessment dated [DATE] at 10:04 PM provided documentation dated 05/19/2019 by a physician at another facility which read: Exacerbation of schizophrenia, acute auditory hallucinations, intentional prescription medication overdose, and acute agitation. Patient was brought to the ED (Emergency Department) after he called police for help. [Patient #2's name] states hearing women's voice in his head that is too much. Admits to taking an intentional overdose of his prescription medications to make voices stop. Patient told the police he wanted to see if he overdosed that hearing voices in his head and are trying to kill him.

Review of the physician's orders dated 05/30/2019 at 1:15 PM read place on 1:1 observation, no gown, no sheets and no pillowcase.

Review of the Nurses' Inpatient Rounds notes for Patient #2 dated 05/30/2019 at 2:37 PM read: Patient #2 attempted to hang himself earlier "because of the pain." He never lost consciousness. Was transferred to ER [emergency room ] for excruciating pain not relieved with medications.

Review of the receiving hospital notes dated 05/30/2019 read: Chief Complaint: Back pain, patient is schizophrenic and admits hearing voices this morning that told him he should attempt suicide to get the pain to stop.

Review of the Nurses' Inpatient Rounds notes dated 05/31/2019 read at 8:09 AM read: "Patient #2 reports he is in physical pain therefore he is feeling suicidal due to not tolerating the pain."

Review of the physician's notes revealed dated 5/31/2019 read: Patient # 2 continues to complain of back pain, sent to hospital and returned with medical clearance, attempted to hang himself with shirt yesterday, labile delusional up all night the night before. Dated 06/04/2019 0/10 depression/anxiety, complaint of back pain.

Review of the Special Treatment checklist revealed 1:1 observation was discontinued on 6/1/2019 as documented by the attending nurse. Patient #2 was receiving every 15-minute checks as documented on the Special Treatment checklist sheet.

Review of the physician's orders for the period of 05/30/2019 to 06/5/2019 revealed there was no order written to discontinue 1:1 observation.

Review of the video for Patient #2 of the incident that occurred on 06/05/2019 revealed the Behavioral Technician did not provide every 15-minute checks, no 1:1 was conducted. Patient #2 was not observed after 05:32 AM due to disruptions on the clinical unit, but documented the observations were being conducted. During change of shift occurring at 7:00 AM the arriving technician began rounds and discovered the consumer in Rm 211 hanging from his gown.

Review of the investigation read: Patient was found hanging in his room on the morning of 6/5/2019. He had tied his grown around his neck and secured it to a hinge of the bathroom door. Staff responded and began CPR until EMS arrived. [Patient #2 did not survive].

Review of the Special Treatment Sheets revealed Patient #2 was to be on 1:1 on 06/05/2019. The Special Treatment Sheet was initialed every 15 minutes indicating the patient was observed every 15 minutes, not 1:1.

During a tour of the Male Psychiatric Care Unit on 01/29/2020 at 4:36 AM shows there were 18 patients with one patient on 1:1 observation, one patient on CVO, two patients were on suicide precautions. The patient on CVO was sleeping on the floor in the day room on a mattress. The 1:1 observation for the Patient identified as #4, the nurse was in the nurse's station when the surveyor entered the unit and proceeded to sit outside the patient's door, approximately 10 - 20 feet from the patient during my tour, with her back toward the patient's room door. Review of the 15-minute check sheets were completed; all sheets were filled out up to 04:30 AM. The observation continued until 5:28 AM and showed the nurse conducting the 1:1 documented on the 15-minute check sheet that the ordered 1:1 was being conducted per the facility procedures.

Patiernt # 4:

Review of the medical record for Patient #4's Biophysical intake assessment revealed a [AGE]-year-old male, who presented involuntarily to the access center under a Baker Act that was initiated by an officer with [the name of the police department] on 1/28/2020. The Baker Act read as follows: Responded to the house for a wellbeing check. [Patient #4's name] called the crisis line yesterday saying he tried to asphyxiate himself two days ago but stopped. He says he is depressed from the time he was in active duty in the army. For this reason, Patient #4 was transported to this facilty. Patient #4 was admitted on [DATE] at 1:15 PM with diagnosis to include severe depression and Schizophrenia.

Review of the physician orders initiated on 1/28/2020 at 1:15 PM read: Suicide precautions (SP) x 24 hours, 1:1 observation x 24 hours. Finger foods, no silverware x 30 days.

Review of the video for Patient #4 was conducted with the Facility RM (Risk Manager) on 01/29/2020 at 3:15 PM and showed:

12:08 AM-12:09 AM staff was not in the doorway or at patient's bedside. Staff was observed walking away from the patients' room. Leaving the patient unattended.
12:12 AM-12:15 AM staff was not in the doorway or at bedside. Staff was observed walking away from room. Leaving patient unattended.
12:24-12:25 AM staff was observed walking away from the room. Leaving the patient unattended.
12:44 AM-12:48 AM: staff was observed walking away leaving patient unattended.
12:53 AM-12:56 AM staff left the patient unattended. Staff was observed walking away from the room.
12:57-1:07 AM staff observed walking away from room, leaving patient unattended.
1:08 AM Staff walked away briefly < 1 minute
1:13 AM-1:14 AM staff walked away leaving patient unattended,
1:16 AM staff walk away briefly < 1 minute.
1:32 AM-1:33 AM staff walked away leaving patient unattended
1:43 AM staff briefly walked away
1:57 - 2:01 AM staff walked away leaving the patient unattended.
2:12 AM staff briefly walk away < 1 minute
2:15-2:22 AM staff walked away leaving the patient unattended.
2:51 AM - 2:52 AM Staff walked away from room
2:57 AM staff walked away briefly <1 minute
3:02 AM Staff walked away from room briefly < 1 minute
3:03-304 AM staff walked away patient was unattended.
3:06 AM staff walked away briefly < 1 minute
3:10 AM - 3:12 AM staff walked away leaving the patient unattended.
Staring at 3:19 AM the staff member placed her chair to the right side of the door to room 206 facing away from the patient's room, facing the nurse's station, not observing the patient on the required 1:1 observation until 4:34 AM when entry was made on the unit at 4:36 AM on 01/29/2020 and observed the staff assigned to the 1:1 in the nurse's station.

During an interview on 1/29/2020 at 3:40 PM, the Facility Risk Manager (RM) stated, "Well, people have to go to the bathroom, but they should be getting staff to cover the patient. I guess they shouldn't leave for even a minute. This is not providing 1:1 or even CVO when staff leave the doorway of the room when the patient is sleeping. They should get someone to cover them and be at the doorway. It is not safe for staff to be in the rooms with patients that is why they can sit or stand in the door of the room. This staff member is sitting outside the room not even facing the patient and that is not our policy and the patient is not being observed as a 1:1 or even a CVO, but she did do every 15-minute checks."

A follow up review of the video was completed on 1/31/2019 at 2:50 PM with the facility DON (Director of Nursing) and the ADON (Assistant Director of Nursing), starting at 12:00 PM on 1/29/2020 and the same prior observations were reviewed.

During an interview on 1/31/2020 at 3:05 PM the DON stated, "This is unacceptable for the patient and does not meet the expectation of 1:1 observation. Staff are to be within arm's reach of the patient at all times, at night we don't feel staff should be in the patients room, so they are to sit in the doorway continually, if they leave they must get someone else to cover the time, even if it is briefly. This staff member should have the special precaution sheet with her and not get up to sign it. It was disturbing enough when she was leaving that frequently, but it was totally unacceptable when she positioned her chair to the side and wasn't even facing the room. All I can say is we did not do the physician ordered 1:1 observation from 3:11 AM until 4:34 AM when you entered the unit. We did put this patient at risk for that entire time when she was sitting on the side of the doorway and facing away from the patient. We did not follow physician orders and we did not follow our policies for patient safety. I think we are in real trouble because this is a potential for harm. I really thought we were doing so much better than this and maybe it's a good thing this happened when you came so we can prevent any further patients' deaths. I'm just sorry it takes this. We are failing our patients, failing to provide a safe environment. We aren't following doctors' orders, checking charts and verifying the correct precautions are being done and not doing CVO or 1:1 observations when administration is not here." A request was made for the documentation of the videos that had been reviewed for patients with orders of CVO, 1:1, and the viewing of agency nurses. No documentation was provided.

During an interview on 02/01/2020 at 11:38 AM with the DON documentation was requested for the viewing of patients for observation under CVO, 1:1, and the agency nurses for compliance with the hospital's policies and procedures. The DON stated, "We don't have any documentation. We did not do video reviews."

During an interview on 1/31/2020 at 2:55 PM with the ADON stated, "Based on this video, we did not provide an adequate 1:1 observation of this patient. Staff need to be within arm's reach of patients when they are 1:1 observation. At night they need to be in the patient's doorway when the patient is asleep. We did not follow the physician order for 1:1 observation. It is my expectation that if staff need to leave the doorway that they get staff to cover them. This patient did not receive 1:1 observation continuously from 3:11 AM until you entered the unit at 4:34 AM. It is not acceptable practice. We expect and need to do much better than this. I do not think that we provided a safe environment for this patient based on what I have seen."

During an interview with Staff M, RN (Registered Nurse) on 1/29/2020 at 04:40 AM she stated, "One on one 1:1 means that you must always be within reach of the patient even when they are sleeping. The staff doing 1:1 was not within arm's reach when you arrived, and she should have been. They had us do the color codes and have pictures of the patients so if we don't know them, we can easily identify them. Honestly, not everyone has a photograph and I don't know who is responsible for making sure they are in the book with the sheets."

During an interview on 01/29/2020 at 4:50 AM, with Staff N, LPN (Licensed Practical Nurse) assigned 1:1 observation for Patient #4, stated, "I am an LPN and am assigned to the 1:1 observation of the patient. I was at the nurse's station when you came in and am supposed to be within reach of the patient. I was before you came in, I was just signing his sheet. I am supposed to be in view of the patient that's why I am outside of the room. When the patient is awake, we are at arm's length when they sleep, we can be in the doorway, visualizing them always. We cannot leave the 1:1 observation patient, if we do someone else must cover them. I cannot leave to go to the bathroom without someone sitting in the doorway. We still initial the sheet and those are my initials on the special precaution's sheets. It shows I was doing the ordered observation."

Patient # 6:

Review of the medical record for Patient #6 revealed the patient was admitted on [DATE] at 1:36 AM to the access center under a Baker Act initiated by a physician at a hospital's ED (Emergency Department) on 12/2/2019 at 7:00 PM stating that patient # 6 had suicidal thoughts and planned to throw self in front of a moving vehicle. Patient # 6 was then transported on 12/10/2019 on a Baker Act (Dated 12/10/2019) and transported by an Officer from the County Sheriff Office on 12/10/2019 at 11:10 PM to the access center of this facilty. Diagnosis includes Bipolar Disorder.

Review of the physician order dated 1/16/2020 at 08:50 AM CVO's. Further review revealed there was no order to discontinue CVO.

A review of the special treatment checklist for the period of 01/16/2020 at 08:50 AM until 01/25/2020 the patient was not on CVO according to the special treatment checklist; only 15-minute checks were documented as having been conducted. The CVO box was not checked to indicate the patient was to be on continuous visual observation. Dated 01/27/2020 from 10:15 PM to 11:00 PM there was no documentation of the patient having even been visualized.

During an interview with the DON on 01/31/2020 at 2:10 PM she stated, "I was not aware that [Patient #6's name] did not have the correct precautions implemented from 01/16/2020 until 01/25/2020. This is again eight days that we did not follow physician orders for the patient. Again, I'm not sure why we didn't do what we are supposed to, and I was not aware of this. No, our plan of correction is obviously not working. This is truly eye opening I thought we were doing a good job at following this plan, we talk about it weekly. I should be doing more than I am. I guess I counted on the fact that the walking lead tech was verifying the orders as well, and the nurses should be verifying these during the chart checks. Maybe they are just signing that they did them."

Patient # 3:

During a tour of the Female PCU (Female Psychiatric Care Unit) on 01/29/2020 at 5:30 AM shows there are eight patients, five patients are identified as suicide precautions, three are on CVO, and one patient is ordered to be on 1:1 observation. Patient #3 was sleeping in the common area room because, as stated by the nurse, she cannot sleep lying down and requests to sleep upright in a chair, Patient #3 was ordered for CVO. There was no staff observed in the common area or the hallway outside of the common area room. A review of the 15-minute check sheets indicated they were filled out to the appropriate time and were not prefilled but indicated the required CVO observation was being conducted per physician order and facility procedures.

Review of the medical record for Patient #3 revealed an admission date of [DATE] via Baker Act and escorted by law enforcement.Diagnosis to include brief psychotic disorder, multiple personality disorder, and Schizophrenia.
Review of the physician's order dated 12/11/2019 revealed SP (Suicide Precautions) x 24 hours, CVO and VAP (Violent Assault Precaution) were ordered. Dated 12/12/2019 the physician ordered SP x 24 hours and VAP. CVO was not discontinued. On 12/16/2019 SP x 24 Hours and CVO was reordered. Dated 1/29/2020 at 7:25 AM CVO/SP due to hanging gown on shower head/self-harm were ordered.

A review of the Special precaution sheets that were available in the chart from 01/03/2020 - 1/14/2020 indicates the patient was on Suicide, VAP (Violent Assault Precautions), elopement and CVO (Continuous Visual Observation).

Starting on 1/15/2020 until 1/24/2020 the patient's Special Treatment Sheets showed the patient was being observed for VAP only by the checking of the VAP box on the sheets.

Starting on 1/24/2020 VAP and CVO precautions resumed and continued.

During an interview on 1/29/2020 at 5:45 AM, with Staff F, an LPN (Agency Nurse Female Unit) stated, "I am an agency nurse and have worked here for about 2 years now. When patients are on special precautions, they are on 1:1 Observation staff must always be within arm's reach of them, at night because it is not safe to be alone with patients, we have a chair and sit in the doorway. We should not leave the patient even to get a drink or use the restroom without someone there with the patient. When patients are on CVO they are always in our vision, that is why they get rooms closest to the nurse's station so we can see them from here. Patient #3 is on CVO, she is in the dayroom, no I suppose she is not on CVO if we are not in sight of her. She has times when it is easier to let her sleep there because she doesn't like to lay flat so many times, she will sleep in there, it keeps her less agitated. We are constantly understaffed, especially on evenings and nights on weekends. The nursing supervisors take multiple units and do the access center. As an agency nurse I am not allowed to help with any type of a patient hold, so when we have an emergency that we cannot deescalate verbally, the staff are placed in a very dangerous situation. The nursing supervisors can't respond when they have other units to cover, it places all patients and staff at risk. It is dangerous for patients and staff when we don't have staff. I have worked with no behavioral technicians too. I have talked to the administrator and director of nursing, but nothing is changing its just getting worse. They are hiring people, but they leave quickly when their licenses are at risk. I refuse to take any more than one unit at a time, they have asked me to do two, but I won't. When that happens, they have the supervisors take the units. They also cover the access units and do the assessments, it's not safe. We did not get any training on these new color codes, they just appeared, and we were told to do them. They don't offer agency nurses any additional training. These patients are not safe when we have no staff. I'm sorry but the administrator understands that we are not safe here. I'm glad you all are here on nights it's about time. You all come on days and everything is perfect, but the problems have been occurring on evenings weekends and nights.

During an interview on 01/29/2019 at 6 :00 AM, with BT Staff F (female unit) stated" I am a fulltime staff member, its almost always short staffed on the weekends on Friday and Saturday nights. They have the nursing supervisors taking multiple units and they are in the access unit too. It seems to have gotten worse lately. I have complained to the Director of Nursing, the assistant director, all the supervisors and the administrator. Nothing has changed, the director of nursing has never worked a shift that I know of. It has become unsafe for the staff and the patients. You all need to check out the staffing sheets. I'm glad you all are here at night to see this. 1:1 observation means we should stay at arm's length of the patients at night we stay in the patient's doorway because it's a safety risk for staff to be alone in a patient's room, continuous visual observation means a staff is always in view of the patient. I have 3 patients on CVO, one of them is in the dayroom, she sleeps in there because she can't lay in bed, she is more comfortable sitting up. That is at the end of the hall. I still do my every 15-minute checks, but no I guess that is not CVO if she is in there and I can't see her. I have initialed the special precaution sheets tonight and they do say that she is in CVO. But they sent a behavioral tech home at 3:00 AM because we are overstaffed for the number of patients we have.

During an interview on 01/30/2019 at 8:12 AM with the RM and the DON a request was made to review the video for Patient #3. It was stated by the RM the camera in that area of the facility is not in operating order and there is no video.

During an interview on 1/29/2020 at 09:39 AM, with Staff I, Lead Emergency Evaluator stated we have an emergency evaluator in access during the day until 7 pm, but we do not have any at night, the nursing supervisor comes to the unit or sends another nurse who is available to assess the patient. There have been times when we must wait for the nurse to come. When that happens, the units are not uncovered there are always an RN and LPN on the units. They are trying to get the night position filled. There has never been a night nurse staff in the access unit. There should be. I know that that was in the facility plan of correction. There has never been a fulltime nurse at night in the access center.

Review of the Special Treatment checklist revealed: Continuous visual observation: if continuous visual observation is ordered, staff must maintain visual contact at all times (including shower and bathroom). If 1:1 is ordered must remain within arms-length of staff at all times.

Suicide assessment and precautions: Reviewed/revised 06/2019 Policy 190-05, procedure 711-10 Purpose: To identify those individuals whose presenting symptoms indicate a high risk of suicidal behavior and to set forth guidelines for staff intervention to minimize such risk. Procedure: IV. Individuals placed on suicide precautions shall be monitored every fifteen (15) minutes for safety throughout the period that the physician orders. Removal from suicide precautions shall occur only by physician order. V. Individuals placed on suicide precautions that verbalize or act in a manner which staff perceives to be indicative of suicidal intent may have continuous visual observation (CVO) ordered by a physician's order based on staff request. Individuals on CVO shall be observed continuously during all hours and notated every fifteen (15) minutes. Observations shall be documented on a form designated for that purpose and included in the clinical record. VII. All individuals placed on suicide precautions, CVO or 1:1 shall be assigned rooms in as close proximity to the nurse's station as possible to allow continuous observation during nocturnal hours.

Review of the Treatment Team Policy #190-05 was reviewed and revised 07/2019 read: Procedure: I: Treatment team will be held daily (including weekends and holidays), III - each individuals case will be discussed during the meeting, including but not limited to: Medication adjustment, competencies, opinions, 1:1 precautions, treatment, discharge and aftercare plans will be formulated.

During an tour of the access unit for safety of the environment on 01/29/2019 beginning at 9:30 AM of the bathroom used by intake patients it showed there was a metal door on the wall to the right of the toilet covering a metal box for the patients to place urine drug screen specimen cups in. Pressure was applied to the metal door, and did not give way which could possibly be a ligature risk. The bottom of the metal door was very sharp and could pose a cutting risk. The plumbing was exposed under the sink, the paper towel holder was made out of a plastic material that could be broken and the pieces used for cutting, the faucet to the sink came up and curved and could pose a ligature risk, the handles for the water supply could pose a ligature risk, and the soap dispenser could pose a ligature risk.

An interview was conducted with the Lead Emergency Evaluator on 01/29/2019 at 9:42 AM and she stated, "When a patient comes in, we give them a urine cup and they go into the bathroom and we wait outside of the door. We will periodically knock and ask if the patient is okay. If they answer we continue to wait." When asked if this would be the same process for a patient who came in from home by law enforcement with a witnessed attempt to commit suicide at home by his mother the Lead Emergency Evaluator stated, "Yes." The Lead Emergency Evaluator verified the bottom of the specimen cup cabinet was very sharp and a patient would be able to cut themselves. When asked how the staff member would know the patient was cutting themselves if a patient continued to answer, the Lead Emergency Evaluator stated, "I wouldn't know a patient was cutting themselves with an object in the room, we don't observe them while they are in the bathroom." The Lead Emergency Evaluator stated, "The faucet, plumbing, water supply handles, the soap dispenser and the paper towel holder could pose ligature risks."

During a tour on 01/29/2020 beginning at 10:00 AM of the Male PCU after entry on the opposite side of entry to the right across the nurses' station were exposed pipes, the wall had a hole toward the bottom, there was a blue tubing observed from a black cylinder into an open and exposed metal pipe. There was an exposed electrical outlet.

During a tour on 01/29/2020 beginning at 10:02 AM of the Geriatric PCU it showed upon entry there was a lowered ceiling with removable white tiles that were eight tiles in length and five tiles in width. The height was approximately eight feet. There is a water fountain on the wall to the right after entry beyond the nurses station that showed it was separating from the wall towards the back of the of the fountain, and the metal piece on the right side was pulled away from the fountain and is a probable cutting risk.

Review of a document that was titled "LifeStream" reads: Subject: Proposed Correction Action Plan. Reference; Environmental Risk Assessment - Inpatient Acute Care Services. To: Vice President QI/RM [Quality Improvement/Risk Management]. CC: To Executive Vice-President. Date: 10/8/2019. In response to these risk assessment general findings I would recommend the following course of action. We need to bring in a knowledgeable anti-ligature expert to develop code complaint specifications which will allow a plan for submission to ACHA [Agency for Healthcare Administration] review and endorsement. Once specifications are complete, we can seek qualifying cost proposals broken down on an individual room basis to make needed installations. Upon receipt of cost proposals and funding approval we will start a systematic installation of room upgrades starting with the close observation rooms as a priority on each unit. Then the hospital management/nursing leadership can ensure that any consumer that is under a suicide protocol be placed into a room that has been upgraded. I have scheduled a meeting with our corporate architect to make a site visits [sic] at our hospital facility tomorrow following our const
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, review of medical records, and Governing Body Bylaws, the hospital failed to maintain and demonstrate an affective functioning Governing Body to ensure all patients were receiving services in a safe setting as ordered by the physician after two patients were successful in committing suicide by hanging, while under physicians' orders for continuous visual observation.

Findings include:

1. the hospital's Governing Body failed to ensure actions were taken by the facility to remove the immediacy for regulatory compliance to provide for patient rights for safety and health care needs after the successful suicide by hanging for 2 of 2 patients, Patients #1 and #2. During a tour on 01/29/2020 additional patients were identifed resulting in 3 Patient's # 3, #4 and # 5 of 6 patients who were ordered 1:1 and/or CVO (Continuous Visual Observation) were not to be monitored as ordered by the physician.

2. The hospital's Governing Body failure to ensure physicians' orders were followed for CVO and 1:1 for patients who are at risk of self harm and/or harm to others. Without proper monitoring this could result in a delay in prevention and treatment with the possibility of death. These systemic failures constitute an immediate jeopardy situation. Refer to A115 Patient Rights, A144 Patient Rights; Care in Safe Setting, A263 Quality Assessment and Program Improvement, and A283 Quality Improvement Activities.

On February 4, 2020 at 11:33 AM, the Senior Vice President Acute Care Services was informed of the ongoing IJ situation which began on June 05, 2019.