HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to ensure:
- The safety of three current high risk suicidal (to cause one's own death) patients (#6, #8 and #9) of seven patients observed in the locked Behavioral Health Unit (BHU) when they failed to remove ligature-risks (anything which could be used for the purpose of hanging or strangulation). (C-2523)
- A psychiatric (relating to mental illness) safe environment free of contraband for one BHU observed. (C-2523)
- The safety of all patients when they failed to educate all staff in response to the attempted suicide of one discharged patient (#27) of one suicide event reviewed. (C-2523)

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 03/11/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on ligature-risks and a safe psychiatric environment. All remaining staff were educated prior to the start of their next shift.

These failed practices resulted in non-compliance with 42 CFR 485.614 Condition of Participation (CoP): Patient's Rights.

Based on observation, interview, record review and policy review, the hospital failed to ensure the safety of three current high risk suicide patients (#6, #8 and #9) of seven patients observed in the locked Behavioral Health Unit (BHU) when they failed to remove ligature-risks (anything which could be used for the purpose of hanging or strangulation). They failed to ensure a psychiatric (relating to mental illness) safe environment free of contraband (items that are illegal, forbidden, or that can be used to harm self or others) for one BHU observed and to ensure the safety of all patients when they failed to educate all staff in response to the attempted suicide (to cause one's own death) of one discharged patient (#27) of one suicide event reviewed.

Findings included:

Review of the hospital's undated policy titled, "Suicide Prevention: Core," showed:
- Patients have the right to be safe in the hospital.
- A suicide attempt is a non-fatal self-injurious act committed with at least some intent to die. There does not have to be any injury or harm, just the potential for injury or harm.
- Patients who have had SI or with suicidal behaviors need additional individualized precautions implemented to keep them safe from their own actions.
- The environment should be immediately cleared of any potentially dangerous items, including but not limited to cords, electrical appliances with cords, any items or areas that may be used as a ligature point or used to bind, loop, or a point of attachment for a ligature should be removed.
- Patients are to be screened using the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life).
- Staff observers must always have a direct, unobstructed view of the patient, including during toileting, bathing, sleeping, etc.
- Implementation and effectiveness of screening, assessment and management of patients at risk of suicide are important to quality improvement; actions are to be taken as needed to improved compliance.

Review of the hospital's undated document titled, "Suicide Assessment and Prevention," showed:
- The BHU should create an environment of care with accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors.
- Staff are to maintain a safe and therapeutic environment for all patients.
- A thorough search of the patient's clothing, belongings and room should be performed to ensure that any items which may be used to inflict self-harm are confiscated.
- All ligatures (shoelaces, belts, cords) and sharps (glass, razors, brittle plastic) should be removed from the environment.
- Staff are to continually monitor the environment and immediately correct or report any identified risks, damage, missing linens or any other change in the environment to their supervisor or Plant Operations personnel for immediate mitigation.

Review of Patient #6's medical record showed a 79-year-old was admitted to the BHU on 03/02/25, with a diagnosis of suicidal ideation (SI, thoughts of causing one's own death). On 03/10/25, her C-SSRS score indicated she was a high-risk for suicide and was placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm).

Review of Patient #8's medical record showed a 70-year-old man was admitted to the BHU on 03/06/25, with a diagnosis of SI. On 03/10/25, his C-SSRS score indicated he was a high-risk for suicide and was placed on SP.

Review of Patient #9's medical record showed a 60-year-old man was admitted to the BHU on 03/04/25, for SI. On 03/10/25, his C-SSRS score indicated he was a high-risk for suicide and he was placed on SP.

Observation on 03/10/25 at 1:53 PM, in the BHU, showed two patients (#6 and #9) were present in the unit's dayroom unsupervised. Multiple dangerous items were left unattended and included:
- A workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) with an unsecured electrical cord attached which was greater than 12-inches in length;
- Three non-psychiatric safe tables;
- Two non-shatter proof plastic chair alarms with metal hooks; and
- A metal bell.

Observation on 03/10/25 at 2:00 PM, in the BHU, showed unsecured patient rooms and a shower room which were accessible to all patients and contained the following hazardous items:
- One thin plastic clothes basket;
- One hard plastic clothes basket;
- One metal walker;
- Two metal bedside commodes;
- One non-shatter proof plastic chair alarm with a metal hook;
- One metal bell;
- One wheelchair;
- Two patient rooms with non-psychiatric safe window curtains;
- Five patient rooms with non-shatter proof plastic paper towel and toilet paper holders; and
- One shower room with non-shatter proof plastic toilet paper and paper towel holders.

During an interview on 03/13/25 at 9:55 AM, Staff N, Chief Nursing Officer (CNO), stated that she expected the BHU to maintain a psychiatric safe environment.

During an interviews on 03/10/25 at 1:53 PM, 03/11/25 at 9:09 AM and 03/12/25 at 10:46 AM, Staff G, BHU Manager, stated that patients could come and go in and out the day room as they pleased. Staff were not always present. All BHU patients were on SP, which did not require a provider order. She expected the BHU to be a psychiatric safe environment. The chair alarms were not supposed to be left on the chairs when not in use. WOWs were not to be left unattended in the patient areas. The tables, curtains, paper towel and toilet paper holders needed to be psychiatric safe. No plastic clothes baskets, metal bells, wheelchairs, walkers or bedside commodes were to be left in patient areas.

Review of the hospital's policy titled, "Observation Levels," updated 06/20/24, showed when patients were assigned a constant one-to-one (1:1, continuous visual contact with close physical proximity) staff member, that staff member was to always remain within arm's length of the patient and to continuously assess the patient's status. Patients on 1:1 observations were to have their rooms searched at the beginning of each shift for potentially harmful objects.

Review of the hospital's document titled, "Current Summary," dated 02/13/25, showed:
- Patient #27 was COVID-19 (highly contagious, and sometimes fatal, virus) positive and awaiting placement into a BH center for SI with an attempt prior to his arrival in the Emergency Department (ED).
- On 02/12/25 at 11:45 PM, while under 1:1 observation he requested to go to the bathroom. He was required to wear a mask in the hallway due to the COVID-19.
- Upon return to his assigned room, the 1:1 sitter straightened the bed linens while he stood next to her. When the patient climbed into the bed, he pulled the blanket over his head.
- The sitter removed the blanked and advised him that he had to have his face exposed. The sitter noticed the patient's face was red almost purple in color and his hand was near the side of his neck.
- The sitter immediately called for help and attempted to move the patient's hand. He had placed the mask loop around his neck and twisted the loop to create a ligature affect.
- The Charge Nurse arrived at the bedside as the sitter removed the mask and the physician was summoned to assess the patient.
- At 11:50 PM, security was notified of the event and responded to the bedside.
- On 02/13/25 at 12:04 AM, the House Supervisor was notified.
- Upon assessment, a red indented ligature mark was noted on his neck. His voice was normal, and his coloring immediately returned to normal.
- Food items, coloring books, crayons, socks and any loose items were removed from his room. The patient began pointing out various items he felt he could use to harm himself, and blankets, pillows and a cup with a straw were also removed from the room.
- The patient stated he was going to "bash his head against the faucet," he then leaned under the cabinet and simulated that process.
- Once Security responded to the bedside and verbally redirected him, the patient laid down on the stretcher and quieted down.
- At 1:05 AM, he removed his paper scrub pants, placed them around his neck and pulled on them in an attempt suffocate. After that, he was only allowed to wear his shirt and briefs. All other items were removed from the room.
-On 02/17/25, the ED Manager reviewed and discussed the event with the staff involved and the administrator on call that night. She signed off on the event.
- There were no follow up tasks identified.

Record review of Patient #27 's medical record showed:
- On 02/11/25 at 7:20 PM, a 12-year-old arrived at the ED after he attempted to ingest pills, drank beer, pointed a gun at his head, said "I am going to commit suicide" and threatened to kill his grandmother.
- At 7:33 PM, he was placed on high SP.
- At 8:21 PM, a 1:1 observation sitter was placed.
- On 02/12/25 at 3:16 AM, he tested positive for COVID-19.
- At 11:45 PM, the patient was up to the restroom with the sitter, a mask in place. Upon return to his room, he stood at the side of the stretcher while the sitter straightened his linens. The patient returned to the stretcher and pulled the blanket over his head. The sitter removed the blanket from his head and noted the patient's face was red/purple. The sitter asked the patient why his face was red and realized the mask loop was over the patient's head and pulled tight around his neck. The sitter immediately removed the mask and called out for help. His assessment noted that his eyes were open, he was alert, his color immediately returned to pink, warm and dry and no loss of consciousness occurred. There were ligature marks to his neck. He was evaluated by the physician and all items were removed from the patient's room. The patient was notified he was not allowed to leave the room and would have utilize a urinal/commode in his room. Security was notified and responded to the bedside for additional monitoring support.
- On 02/13/25 at 12:15 AM, the patient was out of bed, agitated and cussing. He threatened to bash his head on the metal sink in an attempt to kill himself. Security was present, assisted the patient to his bed, all cabinets were locked and there were no loose items in the room.
- At 1:05 AM, the patient removed his paper scrub pants and wrapped the legs around his neck in an attempt to hang himself. The pants were immediately removed, and he was no longer allowed to have pants.
- At 2:47 PM, he was transferred to an in-patient psychiatric hospital.

During an interview on 03/12/25 at 8:15 AM, Staff L, ED Manager, stated that she "briefly" interviewed the nurse who provided the 1:1 observation for Patient #27 during the event. The nurse stated, "it just happened." Staff L indicated that she could have done a better job and pushed the sitter during the interview. The staff were distraught, and the event was disturbing. It was important to walk through the event. All staff present participated in a huddle the following morning. She provided no additional huddles for staff member that were not present at that time. She agreed there was an opportunity for improvement in regard to educating staff in response to the event.

During an interview on 03/12/25 at 10:12 AM, Staff N, CNO, stated that when the patient returned to his room the sitter straightened his sheets. The patient got into bed, pulled the blanket over his head and placed the mask loop around his neck. "The kid was determined." The sitter was "right beside him." She did not interview the sitter. She believed the ED manager did "some education." She expected "refresher" education to be done for the staff. It would have been good to discuss the event in all the huddles. "We could never over educate." It did not hurt to educate all house-wide staff. Other units may have 1:1 patients and this type of event could have occurred anywhere.

During an interview on 03/12/25 at 4:00 PM, Staff Q, Registered Nurse (RN), stated that when the patient exited the bathroom, the mask covered his face. She believed he placed the mask loop around his neck when his head was under the blanket. When he laid down, she removed the blanket from over his head and his face was purple. She pulled the mask off and called for help. His color immediately returned to normal. He had the mask around his neck for no more than 15 to 20 seconds. There was a ligature mark on his neck. After the event, she performed a sweep of the patient's room and found other masks. She followed up with the patient's nurse, the charge nurse, the physician and security. The house supervisor explained the event during the morning huddle, and she reported to the oncoming sitter. She did not recall any follow up with the ED manger. The ED charge nurse followed up with her and explained the details of what to watch for. There was no specific education provided in response to this event. She felt there was an opportunity to learn and share for future situations. She would remove masks from suicidal patients when she provided 1:1 observation.



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