Fhn Memorial Hospital

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42887 Based on observation, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on July 22, 2025, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff. See the Life Safety Code deficiencies identified with K-Tags.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48264 Based on document review and interview, for 2 of 2 patients’ (Pt. #19 and Pt. #20) clinical records reviewed regarding use of violent restraints, the hospital failed to complete a face-to-face evaluation within one hour after the initiation of the restraints. Findings include: 1. On 7/22/2025, the hospital’s policy titled, “Restraints-Protective Devices” (dated 9/01/2023) included, “...Definition: ...A. 2. a. Physical restraints may include ...locking limb restraints ...Method of Implementation: ...B. Behavioral Restraint: ...5. Within one hour of initial application, a behavioral restraint huddle/face-to-face assessment will occur to assess the patient’s response to the intervention as well as evaluate potential factors contributing to the violent or self-destructive behavior ...”. 2. On 7/22/2025, the clinical record for Pt. #19 was reviewed. On 5/17/2025, Pt. #19 presented to the hospital’s ED (Emergency Department) via EMS (Emergency Medical Services) for a stated complaint of delirium (altered mental state of consciousness, episodes of confusion). The record included physician’s orders for behavioral restraints on 05/17/2025 at 7:35 PM and again (renewal order) on 05/17/2025 at 10:04 PM. On 5/17/2025, Pt. #19 was placed in behavioral, violent restraints (four-point restraints) from 7:35 PM through 5/18/2025 at 1:13 AM (5 hours and 38 minutes). The clinical record lacked the required face to face evaluation within one hour after the initiation of restraint. 3. On 7/22/2025, the clinical record for Pt. #20 was reviewed. On 4/19/2025, Pt. #20 presented to the hospital’s ED via EMS due to alcohol intoxication. On 4/19/2025, Pt. #20 was placed in behavioral, violent restraints from 9:00 PM through 10:00 PM (1 hour). The clinical record lacked the required face to face evaluation within one hour after the initiation of the restraint. 4. On 7/23/2025 at approximately 11:50 AM, findings were discussed with the ED Operations Leader (E #11). E #11 stated that a face-to-face must be conducted by a qualified practitioner within an hour after initial restraint application. E #11 reviewed Pt. #19’s and Pt. #20’s medical records and was unable to find a face-to-face assessment post restraint application.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 52901 Based on document review, observation and interview, for 1 of 1 cooler and 2 of 2 freezers in Food and Nutrition (FNS), the hospital failed to ensure that food was properly labeled when opened, as required per policy. Findings Include: 1. The hospital’s policy title, “How to Label a Food Item (7/26/2018)” was reviewed on 07/23/2025 and required, “What information do I include on the labels? Refrigerated/Frozen Food Label.... Product Name, Open/Production/Freeze Date.” 2. During an observational tour of the FNS area on 07/23/2025 from 11:00 AM to 11:45 AM, the following was observed: - At 11:10 AM, in the dairy cooler, an open container of soup was covered with saran wrap and was unlabeled. - At 11:15 AM, in the meat freezer, a package of frozen chunk chicken was opened and unlabeled. - At 11:17 AM, in the vegetable freezer, a large bags of peas, a large bag corn on the cob, and a bag of hash browns were opened and unlabeled. 3. During an interview on 7/23/2025 at 11:25 AM, the Director of FNS (E#12) stated, “All food items must be labeled with date of opening and content of package.””

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 42887 Based on observation, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on July 15, 2025, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 36774 Based on observation, document review, and interview, for 1 of 1 staff (E #3/CRNA/Certified Registered Nurse Anesthetist) observed, the hospital failed to ensure use of antiseptic technique when administering intravenous (IV) medications in the operating room (OR). Findings include: 1. On 7/23/2025 between approximately 9:48 AM through 10:35 AM, an observational tour of the hospital’s OR #2 was conducted. At approximately 10:20 AM and 10:25 AM, E #3 did not wipe Pt. #22’s IV port (access for medications) with an antiseptic pad prior to administration of IV medications. 2. On 7/22/2025, the clinical record for Pt. #22 was reviewed. On 7/22/2025 at approximately 10:10 AM, Pt. #22 was brought to OR #2 for hernia repair. The clinical record indicated that E #3 administered IV anesthesia medications (fentanyl, versed, and ketamine) at 10:20 AM, 10:25 AM, and 10:30 AM, respectively. 3. On 7/22/2025, the hospital’s policy titled, “Safe injection Practices” (7/2024) was reviewed and indicated, “Purpose: To prevent the exposure of patients... to communicable diseases... Method of Implementation. 1. Safe Injection... Intravenous Practices. a. Use antiseptic technique to avoid contamination of sterile injection equipment...” 4. On 7/22/2025 at approximately 10:35 AM, findings were discussed with E #2 (Director Surgical Services). E #2 stated that the intravenous port should be wiped with an alcohol antiseptic prior to administering medications to prevent potential cross-contamination.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 27125 Based on document review, observation and interview, for 3 of 3 (E#6, E#7 and E#8) staff observed in the laboratory, the hospital failed to ensure staff wore gloves, removed gloves, and performed hand hygiene as required per policy. Findings include: 1. The hospital’s policy titled, “Hand Hygiene (10/2024)” was reviewed on 7/22/2025 and required, “Gloves shall be worn when exposure to blood. ... When to de-germ hands [wash] ... After touching patient care equipment or environmental surfaces. ... After removing gloves.” 2. During an observational tour of the laboratory on 7/22/2025 from 1:00 PM to 1:50 PM the following was observed: - At 1:20 PM, E#6 (chemistry technician) had gloves on, touched full blood tubes, placed tubes in the clean blood spinner, returned to the clean blood tube holder and began process again with different full blood tubes. E#6 never removed gloves between tasks or performed hand hygiene. - At 1:25 PM, E#7 (generalist technician) took a blood sample from the work station , placed the tube in the clean refrigerator and returned to the work station with other blood tube samples and began process over again. E#7 had on gloves, never changed gloves between tasks or performed hand hygiene. - At 1:30 PM, E#8 (blood bank technician) took a blood bag out of the refrigerator to dispense to provider. E#8 did not wear gloves while handling blood product or perform hand hygiene after dispensing blood. 3. During an interview on 7/22/2025 at 1:35 PM, the Director of Laboratory (E#5) stated, “Gloves need to be changed between tasks of clean and dirty or when moving onto the next specimen. Staff must always wear gloves when handling blood bags.””

“On July 22, 2025, the Life Safety Code portion of a Re-Certification Survey was conducted. The surveyor was accompanied during the survey walk-through by the following provider representatives: Director Facility Services (DFS) Facility Services Office Manager (FSOM) Sr. Facility Services Manager (SFSM) Rehabilitation at Burchard Hills located at 1010 West Fairway Drive, Freeport, IL 61032 is in a two story building that was constructed in 1928, and a series of additions constructed in 2010. The building, which is of Type II (000) construction, is fully covered by an automatic sprinkler system. The facility was surveyed as an existing business occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 39. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70-2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 482.41 Physical Environment, are MET with no deficiencies cited.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 42887 Based upon observation, Stairways are not maintained in accordance with Code requirements. Failure to maintain Code compliant stairways can impair building occupants’ use of the stair for egress from the building during a fire/smoke event. Findings include: On July 22, 2025, at 11:45am while in the company of the DFS, FSOM, and SFSM it was observed that the top section of stair 6 lacked guard railings that restricted passage of a 4” sphere to comply with 7.2.2.4.5.3. The horizontal separation between the stair runs is greater than the 12” permitted by CMS for approved existing stairs to permit open guards.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 42887 Based on observation illumination of the exit discharge portion of the means of egress is not provided to maintain illumination as required. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way. Findings include: On July 22, 2025 at 3:30pm, while in the company of the DFS, FSOM, and SFSM it was observed that exit discharge lighting was not installed at the exterior exit from exit passageway 1398. This does not comply with 19.2.8, 7.8.1.3”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 42887 Based upon observation, vertical openings between floor levels are not protected in accordance with Code requirements. Failure to protect vertical openings between floor levels can permit the affects of a fire/smoke condition to migrate to other floors to compromise the safety of patients, staff and visitors. Findings include: On July 22, 2025, while in the company of DFS, FSOM, and SFSM, it was observed that fire rated access doors located in stairway shafts were not self closing and self-latching to provide full enclosure and separation of the shaft to comply with 19.3.1, 8.6, and NFPA 80. Locations observed include: A. The door serving stair 1 on the 4th floor observed at 12:20pm. B. The door serving stair 5 on the 3rd floor observed at 1:35pm. C. The door serving stair 6 on the 2nd floor observed at 2:50pm. D. The double door serving stair 1 into room 1398, an exit passageway, on the 1st floor observed at 3:30pm. The door assenmbley is equipped with an astragal, but no coordinator was observed to prevent conflict with the astragal and allow for proper closure of both leaves.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 42887 Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting. Findings include: On July 22, 2025, at 3:00pm while in the company of DFS, FSOM, and SFSM, it was ovserved that room 2130 was used for storing quantities of combustible material and lacked a self-closing/self latching door assembly to comply with 19.3.2.1.3.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 42887 Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event. The finding is: On July 22, 2025, while in the company of the DFS, FSOM, and SFSM, it was observed that sprinkler protected interior spaces are not maintained to prevent the passage of smoke. Failure to maintain smoke tight construction will allow heat, smoke, and products of combustion to bypass to sprinkler heads, which will delay effective operation of the sprinkler system. This does not comply with NFPA 13 2010, 8.6.4.1.1. Locations include: A. At 12:05pm, it was observed in stair 5 on the 5th floor that ceiling tile was not cut to fit around 2 pipe penetrations through the suspended ceiling above. B. At 12:30pm, it was observed in corridor 4020 that the ceiling terminates at cross corridor door framing and that gaps exist between the suspended ceiling systems and glass transoms within cross corridor door framing. The ceiling cavity is exposed on both sides of the frame.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42887 Based on document review and staff interview the facility failed to provied proof of testing of HVAC fire sfety devices. Faillure of protective devices during a fire event risk safety of patients, staff and visitors. The finding is: On July 22, 2025, at 4:15pm in the company of the DFS, FSOM, and SFSM review of the documents for the facilities fire/fire smoke damper testing was available for review. The testing was performed within the required 6 year interval. However, during staff interview FSOM indicated that there are approximately 20 fire/smoke dampers that require corrective measures. No subsequent documentation was available at the time of the survey to indicate corrective actions had been made to comply with NFPA 90A-2012, 5.4.8 and NFPA 80-2010, 19.4.9.1.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain the electrical and medical gas piping systems as required. This deficient practice could affect patients, staff and visitors because a failure of the electrical system could result in failure of the system or electric shock. The finding is: A. On July 22, 2025, at 12:00pm while in the company of the DFS, FSOM, and SFSM it was observed above cooridor 5150 that the medical gas pipe installation is supported by ductwork and in contact with dissimilar metals and therefore not supported as required by NFPA 99-2012, 5.1.10.11.4. B. On July 22, 2025, at 3:50pm while in the company of the DFS, FSOM, and SFSM it could not be determined by direct observation that medical gas piping systems were bonded together and to the building’s grounding electrode system in accordance with NFPA 70-2011, 250.104(B).”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed. Findings include: On July 22, 2025, while in the company of the DFS, FSOM, and SFSM it was observed that multiple electrical receptacles are not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B). Locations include: A. 2 receptacles observed in room 5271 at 11:55am B. Nurses’ station 4329 at 12:20pm”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation the facility is not storing medical gas cylinders in a compliant manner. Failure to properly store medical gas cylinders could result in an increased hazard in a fire event. This deficient practice could affect patients, staff, and visitors. The finding is: On July 22, 2025, while accompanied by DFS, FSOM, and SFSM medical gas cylinders were observed stored not in compliance with NFPA 99-2012, Section 11.3.2. Locations include: A. (5) Type “E” medical gas cylinders were observed in 5112. The room was observed unlocked. B. More than 2 Type “E” medical gas cylinders were observed in 2269. The room was observed unlocked. C. (6) Type “E” medical gas cylinders were observed in 1688. The room was observed unlocked. D. (6) Type “E” medical gas cylinders were observed in 1526. The room was observed unlocked.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The Hospital failed to ensure that safety precautions and appropriate monitoring were in place for patients at risk for suicide. See deficiency at A-144. An immediate jeopardy (IJ) began on 02/10/2024, due to the Hospital’s failure to monitor behavioral health patients that presented to the emergency department, who were at risk for suicide, in order to prevent self-harm or injury. Subsequently, a patient attempted suicide resulting in physical injury and need of resuscitative measures. The IJ was identified on 02/21/2024, at 42 CFR 482.13, Patient Rights. The IJ was announced on 02/21/2024 at 3:30 PM during a meeting with the Interim Chief Executive Officer, the Quality Risk Specialist, the Director of Emergency Services, and Director of Quality. The IJ was not removed by the survey exit date of 02/21/2024.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39802 Based on document review, video review, observation, and interview, it was determined that for 2 of 2 psychiatric patients (Pts. #1 and #11) in the Emergency Department (ED), the Hospital failed to ensure that care was provided in a safe setting by failing to ensure that safety precautions and monitoring were in place. Subsequently, an incident of attempted suicide occurred involving Pt. #1 on 02/11/2024. This has the potential to affect the health and safety of any current or future suicidal patients in the ED. Findings include: 1. The Hospital’s policy titled, “Care Mngmt [Management] Behavioral Health Patient” (revised 10/10/2023), was reviewed and required, “Patients who present to the ED with a history or symptoms of mental illness or emotional disturbance shall be first of all protected from doing harm to themselves and/or others. Self-harm precautions are implemented by the nursing staff for patients who have either harmed themselves, verbalized intent to do so, or indicated, in an overt or covert manner, a wish to do so ... Suicide precautions are initiated in the patient room. Potentially harmful items/equipment are removed ... If the patient scores a Moderate or High Risk on the Suicide Screening Risk Assessment tool and/or has a Petition completed, a sitter/security must be present until the patient is transferred from the hospital ... Emergency Department process for checking belongings: Patient belongings are to be removed from the patient upon arrival. Belongings will be inventoried by 2 staff members ... Personal belongings will be documented using documentation in the electronic medical record ... Observation and/or assessment documentation will occur at least every hour, utilizing the EHR [Electronic Health Record] (Care Rounds) ... Patient will be escorted to and from the designated behavioral health bathroom ...” 2. The clinical record of Pt. #1 was reviewed on 02/15/2024. Pt. #1 presented to the ED on 02/10/2024, at approximately 11:00 PM, for evaluation of hallucinations. - Triage notes included, “Brother and patient admit that patient has been hearing voices, patient states the TV is talking to him telling to go to the tower. Brother reports patient is able to see the radio antenna from his home. Brother states he is reading the bible upside down, patient states the bible voices are telling him to confess his sins. Patient states he hasn’t slept in a couple days ... Patient denies suicidal or homicidal ideations. Patient denies the voices are telling him to harm himself or others ...” - Pt. #1’s Behavioral Health Patient Assessment, dated 02/10/2024 at 11:46 PM, included “Symptoms/Complaint/History: Auditory Hallucinations, Visual Hallucinations, Delusions, Anxiety, Recent Drug Abuse, Not taking psych meds, significant life stressor. Getting Worse ... Suicidal Ideation: None ... In the past two weeks, have you felt down, depressed, or hopeless? Yes ... Interventions: Safe Room and Patient Checklist: ...Suicide Precautions Initiated, All Loose Items Removed from the Room ... Hallucination Type: Auditory, Visual, Command ...” - A Nurse’s Note on 02/11/2024 included, “Patient found by security at 3:08 AM for snoring respirations and discoloration to the head. Security stated this was tied around patient’s neck, holding up a pillowcase. This RN entered the room at 3:08 AM, patient observed unconscious to have snoring respirations, cyanotic head, drooling secretions, radial pulse palpated. This RN called for code blue and assistance. Patient was immediately transferred to room 6 [trauma room] ...” - The record lacked documentation that a staff/sitter was assigned to monitor Pt. #1 while in the ED from the time of arrival until the time of the incident (approximately 3:08 AM). - The Behavioral Patient Belongings Check was not completed until 02/11/2024 at 6:04 AM, which included: “hoodie, grey tennis shoes, socks, belt ...” - Pt. #1 was transferred via ambulance to another hospital for higher level of care due to “Strangulation, esophageal perforation, pneumomediastinum ...” on 02/11/2024 at approximately 9:49 AM. 3. The clinical record of Pt. #11 was reviewed on 02/20/2024. Pt. #11 presented to the ED on 02/19/2024 at 3:03 PM, with a behavioral health complaint. - Pt. #11’s triage note, dated 02/19/2024 at 3:34 PM, included, “Arrived per EMS [ambulance] after attempting suicide. Patient is alert, oriented and cry[ing] on arrival. Made several attempts to cut [Pt. #11] ‘carotid artery’ with a box cutter and also attempted to [hang] from [Pt. #11] bed with a cord to ‘speed up the process’.” - The Psychiatric HPI (History of Present Illness), dated 02/19/2024 at 3:40 PM, included, “ ... [Pt. #11] with a history of mental illness and previous suicide attempts presents after attempting to cut her neck numerous times with a carpet cutter? box cutter? At 12:30 p.m. this afternoon (approximately 2 hours prior to arrival) Pt. #11] states [Pt. #11] tried to wrap something around [Pt. #11] neck as well but did not have the proper cord to hang [Pt. #11] ...states [Pt. #11] was tired and just wanted to die ...” - Pt. #11’s Behavioral Health Patient Assessment included the initial suicide screening on 02/19/2024 at 3:41 PM, indicating that the patient feels depressed; suicidal ideation; admits thoughts of self-harm with plan. Pt. #11’s initial suicide screening score was 4, indicating moderate risk. Subsequent suicide/safety screening scores were scored as high risk (5), on 02/19/2024 at 8:00 PM and then (6) on 02/20/2024 at 8:00 AM. - Pt. #11’s patient’s belongings inventory check was done on 02/19/2024 at 4:52 PM (1 hour 49 minutes after arrival) and did not include stockings. - Pt. #11’s clinical record indicated that a sitter/security was put in place starting on 02/19/2024 at 7:00 PM. The Behavioral Care Rounds notes (that documents interventions in place) indicated that there was a time lapse of a sitter/security guard at the bedside (on 02/20/2024 at 5:00 AM-7:09 AM/2 hour and 7-minute gap) - A Care Rounds Note, dated 02/19/2024 at 11:30 PM (nearly 8 hours after arrival), included, “upon helping patient to bathroom I noticed that she had stockings tied around both of her thighs, given new scrubs, cut off of her legs at this time and pt states, ‘I was going to use those to hang myself.’” - A Behavioral Health Rounds note, dated 02/20/2024 at 7:09 AM, included, “Patient Comfort Provided: Door Closed-Noise Reduced, Lights Dimmed...” - Pt. #11 was transferred to a behavioral health facility on 02/20/2024 at 10:45 AM. 4. Video surveillance footage of the ED on 02/11/2024 was reviewed and indicated that Pt. #1 was roomed in designated behavioral health room (#12) in the ED upon arrival on 02/10/2024 at approximately 11:11 PM. Pt. #1 was accompanied in the ED by the brother and mother. At approximately 1:43 AM, Pt. #1 was escorted by ED Nurse (E#3) to the bathroom across the hall. Pt. #1 went to the bathroom, while E#3 returned to the nurses’ station (with no direct visualization of the bathroom). While Pt. #1 was in the bathroom, E#3 went to another hallway and then back to the nurses’ station, never returning to the bathroom where Pt. #1 was. At approximately 1:48 AM, Pt. #1 comes out of the bathroom and walks towards the nurses’ station to give the sample cup to E#3. At approximately 1:52 AM, E#3 turned off the light in Pt. #1’s room. At approximately 1:54 AM, Pt. #1’s family (brother and mother) walked out of the room (leaving Pt. #1 alone in the room) and the family spoke with E#3 before leaving the ED. At approximately 2:06 AM, E#3 walked past Pt. #1’s room and looked into Pt. #1’s dark room for about a second and then continued down the hall. Between approximately 3:03 AM-3:07 AM, a Security Guard (E#6) was standing at the nurses’ station and had looked into Pt. #1’s room about 5 times. At approximately 3:08 AM, E#6 walks away from the nurses’ station and stops in front of Pt. #1’s room and walks to the doorway to look inside. E#6 turns on the light and walks into the room. E#6 comes out and shortly after, E#3 runs into to the room. Multiple staff (including MD#1) are seen coming to or near the room and bringing the crash cart. At approximately 3:09 AM, Pt. #1 is wheeled out of the room and was taken to the trauma bay. Pt. #1 appeared cyanotic (bluish-purple in color) and unresponsive/unconscious. It was noted that Pt. #1’s belongings were not removed prior to the incident. 5. During a tour of the ED on 02/15/2024 at 10:30 AM, it was noted that the ED had 2 patient bathrooms. One of the bathrooms, was designated for behavioral health patients. The designated behavioral health bathroom had a call light pull cord (approximately 2 feet long). The bathroom door was designed with a break-away lock that allows staff to enter from the outside if emergency entry is required. The Charge RN (E #4) stated that patients are allowed to use the bathroom with the door closed. E #4 stated that the staff should stay outside of the bathroom, when the behavioral health patient is in the bathroom. E #4 attempted to open the door from the external side while it was locked (for demonstration purposes). E #4 was unable to open the door. 6. On 02/20/2024 at approximately 12:00 PM, an additional tour of the ED was conducted with ED Director (E #2). E #2 attempted to open the patient bathroom from the external side. E #2 was able to enter after 1 minute. E #2 stated that there is a pull cord in the bathroom because there are times when non-behavioral health patients use that bathroom, and they may need to call for assistance. 7. An interview was conducted with ED Charge Nurse (E#4) on 2/15/2024, at approximately 3:00 PM. E#4 stated for suicidal patients, “we monitor them when they are in the hallway and visually watch them from the outside. We don’t do direct visualization for privacy reasons.” E#4 stated that after this incident they received an email outlining a process change to remove pillows from behavioral patient rooms and switching to fitted sheets instead of flat sheets. E#4 was not aware of any other changes implemented since the incident occurred. E#4 stated that only patients who are in restraints would receive 1:1 monitoring. E#4 stated that the Hospital does not have designated sitters, they use either security, nursing staff, or the secretary. 8. An interview was conducted with the Director of the ED (E#2) on 2/15/2024, at approximately 3:25 PM. E#2 stated they completed a root cause analysis on Monday (day after the incident) and one of the suggestions was to remove the pillow cases and switching to fitted sheets so that it would be more noticeable if the sheet was being removed from the mattress. E#2 stated that they are still trying to seek out other opportunities to identify additional risk factors that may have led to this incident and could not voice any additional measures implemented in response to this incident. E#2 presented a copy of the email that was sent out to ED staff on 2/13/2024 regarding the new linen protocol for behavioral health patients. 9. Interviews with ED Nurses (E#5 and E#3) were conducted on 02/20/2024, at 9:35 AM and 11:30 AM respectively. Both E#3 and E#5 sated that 1:1 monitoring is only done when a patient is restrained or is agitated/aggressive. E#3 stated that psychiatric patients are able to use the bathroom privately with the door closed. E#3 stated that the nurse does not need to stay by the bathroom door as long as they remain in the vicinity. E#5 was not aware that the bathroom door could be locked. Both E#3 and E#5 stated that patient’s belongings are not removed unless the patient is being involuntarily petitioned for admission. 10. An interview with the Security Guard (E#6) was conducted on 2/20/2024, at approximately 10:00 AM. E#6 stated that E#6 had come to the ED the night of the incident because another patient had arrived in police custody. E#6 stated E#6 had looked into Pt. #1’s room several times due to snoring sounds, but the room was dark and the patient was side lying facing towards the wall (away from the door) and had a blanket/sheet pulled up all the way covering the bottom half of his head and upper body. E#6 stated that some fabric was wrapped tightly around Pt. #1’s neck. E#6 stated that after that a security guard was stationed outside of the patient’s room. E#6 stated that there is usually only two security guards on duty for the whole hospital at night. E#6 stated that E#6 has had no specific training in regards to monitoring of patients. 11. An interview with the Quality Risk Specialist (E#1) was conducted on 2/20/2024, at approximately 11:45 AM. E#1 stated that besides removing the pillowcases and changing to fitted sheets, no other corrective actions have been taken thus far in response to this incident.”