Geisinger-Community Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21559 Based on the seriousness of the non-compliance and the potential harm to staff, visitors and other patients, the facility failed to protect a patients right to receive care in a safe environment. The facility failed to ensure individuals entering the Emergency Department (ED) were wanded from head to toe and back and the facility failed to ensure individual’s handbags, purses and knapsacks were visibly inspected for weapons or contraband for two of two patients observed (MR6 and MR7) and for three of three visitors observed (visitors accompanied MR6 and MR7); the facility failed to prevent patients who entered the ED were free of contraband that could potentially harm staff, visitors and other patients for three of three applicable medical records reviewed (MR1, MR2 and MR3) and the facility failed to ensure a patient entering the facility’s ED for a psychiatric evaluation due to fleeting suicidal thoughts was wanded in a timely manner for one of one applicable medical record reviewed (MR3). A discussion took place with EMP1, EMP2, EMP3, EMP4, EMP7, EMP9 and OTH6 regarding the survey team’s concerns related to the Patient Rights on March 18, 2025. Cross reference 482.13 (c)(2) Patient Rights: Care in Safe Setting”

“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: 38776 Based on observations, facility documents, and staff interview (EMP), it was determined the facility failed to ensure individuals entering the Emergency Department (ED) were wanded from head to toe and the facility failed to ensure individual’s handbags, purses and knapsacks were visibly inspected for weapons or contraband for two of two patients observed (MR6 and MR7) and for three of three visitors observed (visitors accompanied MR6 and MR7); the facility failed to prevent patients who entered the ED were free of contraband that could potentially harm staff, visitors and other patients for three of three applicable medical records reviewed (MR1, MR2 and MR3) and the facility failed to ensure a patient entering the facility’s ED for a psychiatric evaluation due to fleeting suicidal thoughts was wanded in a timely manner for one of one applicable medical record reviewed (MR3). Findings include: Review on March 18, 2025, of the facility’s “Patient rights & responsibilities” brochure, A-775-001 F ENG-BR Dev. 6/21, revealed “...Care delivery You or your legally authorized representative or guardian have the right to...Receive kind, respectful, safe, quality care delivered by skilled staff...” Review on March 18, 2025, of the facility’s “Mission Statement Security” policy, last template version January 10, 2024, revealed “Policy Geisinger Security Services protects and serves by providing the following: 1. Protecting patients, visitors, and employees from harm and reasonable fear of harm. 2. Maintaining an acceptable level of order, control, security and safety, and emergency response capability in the various hospital and support facilities, and throughout the organization...5. Enforcing established organizational policies, procedures rules, and regulations. 6. Utilizing security technologies as appropriate to reduce risk and enhance protection capabilities...” Review on March 18, 2025, of the facility policy, “Metal Detector,” last reviewed January 10, 2024, revealed “... Purpose The purpose of this policy is to promote safety and provide guidelines concerning magnetometer use for the facilities that deploy them as part of their security operations. This policy is intended to be flexible in that deviations based on clinical judgment are permissible provided the intent of this policy is served. Persons Affected This policy applies to all security personnel who operate or otherwise participate in magnetometer screenings at a Geisinger-owned or leased facility. Policy A. To promote and increase the physical safety of Geisinger staff, patients, and guests, magnetometers will be strategically deployed at select entrances to Geisinger facilities or departments that have demonstrated a need for increased security measures. The following guidelines relate to Geisinger locations where access is controlled using an operational magnetometer: 1. Magnetometers shall be operational only when trained uniformed security staffing levels permit. 2. Except for patients presenting with urgent/emergent medical symptoms such as chest pains, shortness of breath, arrival by emergency vehicle and except as otherwise provided in this policy, all individuals desiring to pass through an entrance controlled by a magnetometer will be required to pass through the magnetometer’s zone of detection. 3. Signs stating the following information should be posted near any entrance that is controlled by a magnetometer: Firearms and weapons are prohibited. Magnetometer(s) are in operation and any person(s) refusing search may be denied entry to the controlled area. Weapons, dangerous devices, illicit drugs, and contraband will be handled in accordance with existing Geisinger policy and will not be permitted entrance into a Geisinger facility. Security lockers, or equivalent, will be provided for storage of legally possessed items (e.g., knives that meet the legal requirement, personal defensive chemical agents), and personal hand luggage, purses or bags that are not otherwise screened. 4. Anyone refusing a visible search of purses, backpacks, etc. will be advised to secure their items prior to entering the area that is controlled by the magnetometer. B. Searches in Conjunction with Magnetometer Screening: 1. In conjunction with screening visitors entering facilities with a magnetometer, security personnel may also visually inspect bags, purses, knapsacks, briefcases, etc. In such instances, the visitor may be asked to remove items from his or her bag, purse, knapsack, and/or briefcase to facilitate the visual inspection. 2. When a search is determined to be appropriate, reasonable attempts will be made to secure the individual’s cooperation in conducting the search. An explanation of the reason(s) for the search is to be provided. Searches are conducted by trained security officers as quickly as possible to accomplish a thorough search in a manner respectful of the individual and his or her possessions. 3. Luggage, large bags, and other items as determined by security personnel are to be placed in an appropriately secured area within the general vicinity of the magnetometer. Transactions are recorded using an inventory control system that is managed by the site security. Individuals who must relinquish item(s) are informed that they are to be accompanied by security if they wish to obtain any items from the bags after they have been properly secured. 4. When the person who originally checked the items is leaving the facility the items will be returned. Such transactions are recorded using the inventory control system as managed by the site Security Department. C Handheld Magnetometer Use: 1. Any person who, by virtue of their physical condition is incapable from passing through the detection zone of the magnetometer should be “wanded” utilizing a handheld magnetometer. 2. Those with implanted medical devices will occasionally cause an activation of the magnetometer as they walk through. In such cases that the operator has reason to believe this has occurred, the person will be additionally screened with the handheld magnetometer. 3. Handheld magnetometers may be employed as needed and at any time deemed necessary by security personnel provided the provisions set forth in this policy are adhered to. 4. Individuals entering a controlled Emergency Department area via the Ambulance Entrance may also be subjected to a handheld type of magnetometer screening of their person as well as a visual inspection of the contents of any bags, purses, backpacks, briefcases, etc. Notwithstanding the foregoing, in no event will this screening interfere with patient care. D. Disposition of Weapons: 1. All weapons must be relinquished as a condition of entry. A claim-check, lock box, or similar inventory control should be used, and the affected person is advised of where and how to seek return of the item prior to leaving the premises. 2. When a person seeking return of a firearm does not demonstrate that he or she holds a valid license to carry/permit, the firearm will not be returned. In those instances, the firearm shall be relinquished to law enforcement Definitions A. Firearm - A weapon that uses explosives to propel a projectile, including without limitation any gun, pistol, revolver, shotgun or rifle or similar item as described in applicable federal, state, and local laws. B. Weapon - An device, machine, tool, or instrument capable of inflicting harm, including but not limited to any firearm, explosive device (e.g., bomb, grenade, etc.) knife, cutting instrument, cutting tool, blackjacks, sandbags, metal knuckles, daggers, razors, nun-chuck stick, and any other tool, stun gun, stun baton, Taser or other electronic or electric weapon or other implement for the infliction of bodily injury, and anything Geisinger security reasonably conclude could be used as a weapon, whether or not it has another legitimate purpose. C. Magnetometer - A machine or device that uses an electromagnetic field to detect metal objects, such as concealed handguns, weapons, or metal objects. ...” Review on March 18, 2025, of the facility’s “Handling of Contraband and Illegal Items Including Drugs and drug Paraphernalia” policy, last template version January 10, 2024, revealed, “Purpose This policy establishes the process for identifying, handling and reporting of patient possession or use of Contraband, including guidelines for the proper collection and custody of illegal items, until such time as those items can be returned to the patient, turned over to the police or disposed of properly, as applicable...Policy Geisinger does not allow the possession and/or use of Contraband in or on Geisinger property... For the protection of its employees, patients and visitors, Geisinger uses its best efforts to handle and process illegal items...Definitions...Contraband means any drug coming under the Controlled Substances Act, when used illegally, or drug paraphernalia or weapons or devices calculated to inflict serious bodily harm (whether or not illegal (i.e., pocketknife)). Some Contraband is not necessarily illegal but given Geisinger’s desire to provide a safe environment for its patients, visitors and employees, it is not allowed on Geisinger property...” Review on March 18, 2025, of the facility’s “Suicide/Self-harm Precautions - Nursing” policy, last reviewed September 19, 2024, revealed “Purpose The purpose of this policy is to ensure an effective method for suicidal assessment, monitoring, and treatment of patients at risk for suicide/self-harm or who may endanger others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm...Responsibilities All Geisinger staff are responsible to ensure a safe environment for patients with suicidal ideation...” Review of the power point presentation provided by EMP6 on March 18, 2026, revealed staff review this when they are hired. Further review of this power point revealed “Screening Procedures 1. Request that the individual remove any excessive metal. Such as keys, studded belts, etc and all items from cloths pockets and place them in a designated inspection tray. 2. Request that the individual remove any cold or wet garments (e.g. hat, overcoat, rain gear, etc.) and place them on the devesting table for inspection. Physical inspections should consist of feeling the garments for hidden objects. 3. Visually screen the individual for any type of suspicious or hidden items including the outline of an unidentified object. 4. Request that the individual open any container that he or she may be carrying (e.g., lunch box, purse, briefcase) and visually inspect the contents. Hand Wand Screening Request that the individual raise both arms straight out to shoulder height with his or her palms open facing the floor and stand with their feet approximately shoulder width apart. Pass the hand wand over the individual’s body at 1 inch. - Important: Avoid touching the individual’s body or clothing with the metal detector. Orientation of the handheld should be horizontal while scanning the torso and vertical while scanning the legs/shoes. Vertical orientation near the floor (concrete) will limit false alarms The body scan should be performed each time in the same pattern so that the operator always knows what parts of the body still needs scanned. Start at the top of one shoulder of the individual, with the paddle of the detector held parallel to the front of the body. Sweep down one side of the torso, down the leg to the floor (shoe). Next, move to the other leg and sweep up from the floor (shoe) of the opposite leg and torso. End with the opposite shoulder. Sweep the hand wand over the outside top of the arm from the top of the shoulder to the bottom of the wrist, then up the inside of the arm to the armpit. Sweep down that side of the body to the floor (shoe) and continue back up the other leg from the floor (shoe) to the underarm. Repeat the sweep of the inside and outside of this arm. The diagram includes sweeping of the head from one side to the other side, Important: Avoid touching the individual’s body or clothing with the metal detector” Observation on March 18, 2025, at approximately 1010, revealed patients and visitors entering this entrance. The following were the observations: 1. Observation of MR6 on March 18, 2025, at 1010 revealed this patient entered the ED Ambulatory Entrance. MR6 placed belongings on a table; EMP5 stood in front of the MR6’s body and wanded this patient from shoulders to the feet. EMP5 then allowed MR6 to proceed to Registration. EMP5 did not wand MR6’s head. Further observation revealed EMP5 did not have this patient turn around to wand the back of MR6’s body before allowing this patient to proceed to Registration. Review of MR6 on March 18, 2025, revealed this patient presented to the ED for evaluation and treatment of cold symptoms. 2. Observation of visitor of MR6 on March 18, 2025, revealed this visitor entered the ED Ambulatory Entrance. The visitor of MR6 placed belongings on a table; EMP5 stood in front of the visitor of MR6’s body and wanded this visitor from shoulders to the feet. EMP5 then allowed the visitor of MR6 to proceed to Registration. EMP5 did not wand the visitor of MR6’s head. Further observation revealed EMP5 did not have this visitor turn around to wand the back of the visitor of MR6’s body before allowing this patient to proceed to Registration. 3. Observation of a second visitor of MR6 on March 18, 2025, revealed this visitor entered the ED Ambulatory Entrance. The second visitor of MR6 placed the purse/ backpack on a table; EMP5 stood in front of the second visitor of MR6’s body and wanded this visitor from shoulders to the feet. EMP5 then allowed the second visitor of MR6 to proceed to Registration. EMP5 did not wand the second visitor of MR6’s head; EMP5 did not have this visitor turn around to wand the back of second visitor of MR6’s body and EMP5 did not visibly inspect this visitor’s purse/ backpack before allowing this patient to proceed to Registration. 4. Observation of MR7 on March 18, 2025, revealed this patient entered the ED Ambulatory Entrance. MR7 placed the purse/ backpack on a table; EMP5 stood in front of the MR7’s body and wanded this patient from shoulders to the feet. EMP5 then allowed MR7 to proceed to Registration. EMP5 did not wand MR7’s head; EMP5 did not have this patient turn around to wand the back of MR7’s body and EMP5 did not visibly inspect this patient’s purse/ backpack before allowing this patient to proceed to Registration. Review of MR7 on March 18, 2025, revealed this patient presented to the ED for evaluation and treatment of vomiting. 5. Observation of a visitor of MR7 on March 18, 2025, revealed this visitor entered the ED Ambulatory Entrance. The visitor of MR7 placed belongings on a table; EMP5 stood in front of the visitor’s body and wanded this patient from shoulders to the feet. EMP5 then allowed the visitor of MR7 to proceed to Registration. EMP5 did not wand the visitor of MR7’s head. Further observation revealed EMP5 did not have this patient turn around to wand the back of the visitor’s body before allowing this visitor to proceed to Registration. Interview on March 18, 2025, with EMP5 and EMP7, at approximately 1020 confirmed MR6, MR7, visitor of MR6, second visitor of MR6, and visitor of MR7 entered the facility; these patients and visitors were not wanded from head to toe and their belongings were not visibly inspected for weapons or contraband. Interview on March 18, 2025, with EMP6, at approximately 1430 confirmed patients and visitors were required to be wanded from head to toe, front and back when the stationary metal detector alarmed. EMP6 confirmed patient and visitor belongings and bags required more than a brief glance into the bag and a physical inspection for weapons or contraband. Review of MR1 on March 18, 2025, revealed this patient presented to the ED on February 15, 2025, following a seizure resulting in loss of consciousness. MR1 was admitted to an inpatient unit on February 15, 2025, at 2120. Review of MR1 on March 18, 2025, revealed nursing documentation dated February 15, 2025, at 2236, this patient’s belongings included electronic devices, shirt, pajamas, underpants and a cell phone. Review of MR1 on March 18, 2025, revealed this patient’s bed alarm was sounding; MR1 was pacing in the room, wanting to leave; security was at the bedside; MR1 was refusing to cooperate and charged the doorway. MR1 and a security guard fell to the floor, after being helped up the security noticed bleeding from this employees abdomen. A pocket knife was found on the floor and given to security. Review of MR1 on March 18, 2025, revealed no documentation this patient was wanded when entering the ED. Review on March 18, 2025, of the facility’s investigation revealed no documentation determining how the pocket knife entered the facility. Interview with EMP1, EMP3, EMP4 and EMP9 on March 18, 2025, confirmed the above findings at the time of the review. MR1 was discharged on February 16, 2025. Review of MR2 on March 18, 2025, revealed this patient presented to the facility through the ED Ambulatory Entrance on March 1, 2025, at 1854, for evaluation and treatment of right knee pain. Interview with EMP3, EMP4 and EMP9 on March 18, 2025, revealed when MR2 entered through the ED Ambulatory Entrance, this patient walked through the metal detector Tower and was scanned for contraband, including knives. Review of MR2 on March 18, 2025, revealed nursing documentation dated March 2, 2025, at 2040, this patient’s belongings included clothing. Review on March 18, 2025, of the facility’s report dated March 1, 2025, revealed security documentation that MR2 was checked by contracted Professional Security Service [name of company]; there was no report of a knife being found and that an ED staff person reported this patient had a knife on the side attached to the belt. Further review revealed documentation this patient went through the door and was not properly wanded. Interview with EMP1, EMP3, EMP4 and EMP9 on March 18, 2025, confirmed the above findings at the time of the review. Review of MR3 on March 18, 2025, revealed this patient presented to the facility through the ED Ambulatory Entrance on March 4, 2025, at 1308 for a psychiatric evaluation due to fleeting suicidal thoughts. Interview with EMP3, EMP4 and EMP9 on March 18, 2025, revealed when MR3 entered through the ED Ambulatory Entrance, this patient walked through the metal detector Tower and was scanned for contraband, including knives and metal objects. Review of MR3 on March 18, 2025, revealed nursing documentation dated March 4, 2025, at 1430 indicating this patient changed into blue scrubs and was wanded by security. Further review of MR3 documentation when security wanded MR3 the following were found: 1 knife,1 flat black knife with a foldout blade, 1 Ring Spike and 1 Black strap. Review on March 18, 2025, of the facility’s report dated March 4, 2025, revealed no documentation indicating an investigation into how the above items were able to enter through the ED Ambulatory Entrance. Interview with EMP1, EMP3, EMP4 and EMP9 on March 18, 2025, confirmed the above findings at the time of the review.”

“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: 21559 Based on review of facility documents, observation, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure a suicidal patient ordered one-on-one Direct Visualization was not left unattended behind a closed bathroom door (MR1); the facility failed to ensure the 1:1 sitter had direct visualization of a suicidal patient ’ s hands, arms and face (MR22) and the facility failed to ensure a 1:1 sitter was not behind a closed door with a patient ordered on direct visual observation (MR23) and the facility failed to ensure a patient expressing suicidal thoughts was rescreened as per facility policy for one of one applicable medical record reviewed (MR1). Findings include: Review on March 14, 2025, of the facility’s “Patient rights & responsibilities” brochure, A-775-001 F ENG-BR Dev. 6/21, revealed “...Care delivery You or your authorized representative or guardian have the right to...Receive kind, respectful, safe, quality care delivered by skilled staff...” Review on March 14, 2025, of the facility’s “Guidelines for the Care of Behavioral Health in the Emergency Department” policy, last template version 22.02 May 16, 2022, revealed “Purpose To Provide care for patients with behavioral health complaints or psychotic manifestations including homicidal or suicidal ideation. To provide guidelines for a comprehensive assessment and maintenance of patient safety during their time in the Emergency Department (ED). This includes but is not limited to the completion of a suicide risk screening, medical screening exam (MSE), assessment of the environment and referral for behavioral health evaluation...Steps A. Process for direct admission to Behavioral Health Holding Area (BHHA) 1. Patients presenting with behavioral health complaints (including suicidal or homicidal ideation) or signs of psychosis to triage or via EMS (without overt signs/symptoms of medical issues) will be triaged by trained personnel, suicide Risk screening completed, and will have an Emergency Severity Index (ESI) level determined...If Columbia screening results in “NA”, staff will consider use of CVM. Staff will follow procedures outline in the policy: “Suicide/Self-harm Precautions-Nursing”. 2. Patient will be roomed according to ESI Level and need for safety/security...10. Patients requiring 1:1 direct visualization must be observed by nursing staff for safety while in the bathroom and shower...” Review on March 14, 2025, of the facility’s “Suicide / Self-Harm Precautions - 10.60.4” policy, last committee approval October 11, 2022, revealed “Purpose The purpose of this policy is to ensure an effective method for suicidal assessment, monitoring, and treatment of patients at risk for suicide/self-harm or who may endanger others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm...Definitions Columbia Suicide Severity Rating Scale (C-SSRS) - Evidence based suicide risk assessment tool to assess suicidal ideation. Continuous observation - continuous in person 1:1 observation monitoring for high risk patients Direct Visual Observation - constant observation in person or by video for moderate risk patients. Observation of multiple patients (no more than 2:1 in person) or can utilize in person and video monitoring for patients simultaneously per nursing/provider judgement...Suicide Ideation - specific behaviors/thoughts/ verbal cues which may be indicative of an individual’s intent to kill oneself...Procedure...Any patient that arrives to Emergency department with active suicide attempt is automatically placed on high risk 1:1 observation. Emergency Department Complete the Columbia Suicide Severity Rating Scale (C-SSRS) on every Adult patient and the RSQ-4 for pediatric patients 11-17 years of age. The patient will be re-assessed with any change in patient behavioral condition to determine if a change in risk level (adults) and/or intervention is needed ... “ Review on March 14, 2025, of the facility’s “Geisinger Health Suicide Assessment Risk Score & Interventions” protocol, no review date, revealed “Low Risk Locate patient close to nurses’ station, if possible. Rescreen patient using CSSR if change in behavior, statement, or condition. Ensure resources are provided at discharge, if needed. Moderate Risk Alert provider and charge nurse of status. Psych consult as ordered by practitioner. Assign to direct visual observation, may assign video and/or continuous in person. Locate patient close to nurses’ station, if possible. Complete room and body search immediately for any potentially harmful objects. Screen all visitor belongings. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge. High Risk Alert provider and charge nurse of status. Assign to 1:1 continuous in person visual observation. May use video monitoring as secondary precaution in conjunction with direct 1:1. Psych Consult as ordered by practitioner. Locate patient close to nurses’ station, if possible. Complete room and body search immediately for any potentially harmful objects. Remove pt. belongings. Screen all visitor belongings. Paper scrubs. Plastic dinnerware. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge.” 1. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure. Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1’s room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343. Review of MR1 on March 10, 2025, at 1617 revealed documentation MR1 was transferred from ED room 32 to the locked ED Behavioral Health unit (Nurses Station 4) room 31. Review on March 14, 2025, of MR1’s nursing documentation dated March 11, 2025, at 1030 revealed EMP5 opened the bathroom door; visualized MR1 in a fetal position on the ground with a plastic bag around the neck attempting to strangle self. Scissors were used to remove the plastic bag from around MR1’s neck. MR1 was escorted back to the locked ED Behavioral Health unit (Nurses Station 4) and assessed for injury. Interview with EMP1 revealed EMP6 escorted MR1 out of the locked ED Behavioral Health unit (Nurses Station 4) to the bathroom directly outside this unit and left MR1 unattended in the bathroom for an undetermined amount of time. There was no nursing documentation indicating the time MR1 was escorted to the bathroom located outside of the locked ED Behavioral Health unit (Nurses Station 4). Interview with EMP1 on March 14, 2025, confirmed the above findings at the time of the medical record review. EMP1 revealed EMP6 was the assigned one-on-one direct visual observer assigned to MR1. Observation on March 14, 2025, of the bathroom located directly outside the locked ED Behavioral Health unit (Nurses Station 4) revealed the following ligatures that pose a hanging threat to a patient with suicidal thoughts or ideas: A slotted paper towel holder A nurse call bell cord A commode with exposed pipe Handrails along the back and left side of the commode with an open rail Goose neck faucet Louvered hot and cold-water handles Goose neck sink drainpipe A metal hook on the back of the door that was not break away Louvered door hand Interview with EMP1, EMP3 and EMP4 confirmed the above ligatures in the bathroom. EMP1, EMP3 and EMP4 confirmed the above ligatures pose a risk to a person with suicidal thoughts or ideas. 2. Review of MR22 on March 14, 2025, revealed this patient presented to the ED on March 14, 2025, at 0121 following a suicide attempt by crashing of the motor vehicle. The facility completed a Columbia - Suicide Severity Rating Scale and determined MR22 met the criteria for Suicide 1:1/Direct Visual Observation. MR22’s Suicide 1:1/Direct Visual Observation began on March 14, 2025, at 0150. Observation of MR22 on March 14, 2025, at approximately 1330 revealed this patient lying in bed facing down with hands and arms not visible to the 1:1 observer. Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary to see a suicidal patients, hands, arms and face to ensure their safety. 3. Review of MR23 on March 14, 2025, revealed this patient presented to the ED on March 13, 2025, at 1203 following suicidal behaviors and statements. Nursing documentation dated March 13, 2025, indicating MR23’s parent reported violent outbursts of biting, hitting, kicking and verbally threatening prior to coming to the ED. Nursing documentation dated March 13, 2025, revealed nursing also reported MR23 had violent outbursts of biting, hitting, kicking and verbally threatening nursing staff on admission to the ED. The ED physician ordered MR23 on Suicide Precautions on one-to-one Direct Visualization. MR23’s one-to-one Direct Visualization began at 1207 on March 13, 2025. Observation of MR23 on March 14, 2025, at approximately 1330 revealed this patient’s ED room door closed with the one-to-one Direct Visualization sitter behind this closed door. Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary for one-to-one Direct Visualization sitters to leave the patient room door open to ensure the staff safety. 4. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure. The facility completed a Columbia Suicide Severity Rating Scale on MR1 on admission to the ED and determined this patient’s risk for suicide was zero. Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1’s room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343. There was no documentation in MR1 indicating the facility completed a reassessment of MR1’s suicide risk by completing another Columbia Suicide Severity Rating Scale. Interview with EMP1 confirmed the above finding at the time of the medical record review. Cross reference 482.13 Patient Rights”