Bhc Fairfax Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38532 . Based on interview, record review, and review of hospital policies and procedures, the hospital failed to protect and promote patient rights. Failure to protect and promote each patient’s rights risks physical and psychological harm. Findings included: 1. Failure to provide each patient with a means to protect the patient’s right to personal privacy in the seclusion room Cross Reference: Tags A0143 2. Failure to ensure that it implemented its ligature risk mitigation plan for ligature risks in the patient care area identified by the hospital. 3. Failure to identify and then develop an appropriate ligature risk removal or mitigation plan in patient care areas. 4. Failure to develop and implement a comprehensive, accurate Ligature Risk, Prevention, and Mitigation Plan. Cross Reference: Tags A0144 Due to the scope and severity of deficiencies under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET. .”

“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: 38532 . Based on observations, document review, and interviews, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients. Failure to maintain a safe environment risks patient harm and death. Findings included: 1. Failure to ensure that it implemented its ligature risk mitigation plan for ligature risks in the patient care area identified by the hospital. 2. Failure to identify and then develop an appropriate ligature risk removal or mitigation plan in patient care areas. 3. Failure to develop and implement a comprehensive accurate Ligature Risk, Prevention, and Mitigation Plan. Cross Reference: Tags A0701 The cumulative effects of these systemic problems resulted in the hospital’s inability to assure a safe and secure physical environment for patients. Due to the scope and severity of deficiencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET. .”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 38532 . Based on observation, and interview, the hospital failed to provide each patient with a means to protect the patient’s right to personal privacy in the seclusion room. Failure to provide for privacy puts patients at risk for loss of personal dignity and psychological harm. Findings included: 1. On 06/11/25 between the hours of 10:30 AM and 11:00 AM Surveyor #1 and the assistant chief operation officer (Staff #104) observed the seclusion room on the north unit. Observation showed a large tear of the privacy frosted window covering that looks out directly into the patient courtyard so much so that patients in the courtyard can come up to the window and look into the seclusion room. 2. During the observation the surveyor interviewed Staff #104 regarding the process of work orders. Staff #104 indicated that any staff can place a work order in the facility’s software program called “The Dude” so that facility staff is aware of areas that need to be fixed. Staff #104 showed an entry was made to fix the window at 1:41 PM after the observation. .”

“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: 38532 . Item #1 Ligature Risk Mitigation Based on observation, interview, and document review, the hospital failed to ensure that it implemented its ligature risk mitigation plan for ligature risks in the patient care area identified by the hospital. Failure to mitigate ligature risks can result in patient harm and death related to suicide by hanging. Findings included: 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed the following: a. North Unit i. Potential Area of Risk: Door Closures, if necessary, are mounted on the hall side. ii. Comment/finding: Yes iii. Mitigation Strategies: “Staff presence in hallways; hallway is under continual supervision.” b. Fairfax Everett Behavioral Health Hospital i. Potential Area of Risk: On-Unit Day Room and Group Room: Door closures, if necessary, are mounted on the hall side ii. Comment/finding: No-door closures mounted on the room side in South Consult room and both day rooms. iii. Mitigation Strategies: Continuous in-person monitoring anytime a patient is in this area. 2. On 06/10/25 at 10:08 AM, Surveyor #5 and the Nurse Manager (Staff #502) inspected Kirkland Campus North Unit. Surveyor #5 observed a hallway that contained 2 patient rooms (#138, a single patient room, and #139, a double patient room), as well as the Seclusion room. The main hallway connected to this hallway in a T shape. At the end of this hallway was a door (located between room #138 and #139 that opened to a courtyard.) Surveyor #5 noted that the door closure device that opened to the hallway was a closed-loop hinge. At the opposite end of the hallway near the nurses’ station, Surveyor #5 observed a double door where one door opened to this hallway, and one opened to the main hallway. Both door closure devices were the close-hinged type. Surveyor #5 observed the hallway for approximately 30 minutes and noted that there was no direct supervision of the hallway by staff. 3. During the interview with the Manager (Staff #501), the 2 hallway cameras were not monitored but can be reviewed if problems are identified. 4. On 06/13/25 at 9:30 AM, Surveyor #5, the Director of Risk (Staff #501), and an Assistant Administrator (Staff #503), inspected the physical environment for Fairfax Behavioral Health Hospital Everett. Surveyor #5 observed a closed-loop door closure device on the exit door by Room #708. Surveyor #5 noted 2 closed-loop door closures on the fire doors near room #713. Surveyor #5 observed the hallway for approximately 5 minutes and noted that there was no staff supervision of the hallway. At this time, Surveyor #5 requested information related to suicide precautions or suicide risk for the patients who were in rooms #709 and #713 at the time of the observation. 5. At the time of the review, Staff #501 verified that there was not a staff member providing continuous direct observation of the hallway with the ligature risks and stated that there were staff present in the area and that staff were doing rounds monitoring the patients. Staff #501 verified that the Patient in Room #708 at the time of the observation was on Suicide and Fall Precautions (Patient #501). 6. On 06/13/25 at 9:50 AM, Surveyor #5, the Director of Risk (Staff #501), and an Assistant Administrator (Staff #503), continued inspection of the physical environment for Fairfax Behavioral Health Hospital Everett. Surveyor #5 observed a Day Room near the entrance to the facility with 6 unsupervised patients inside the room. Surveyor #5 observed the 6 patients in the room for approximately 5 minutes. Surveyor #5 found no evidence that staff were observing the room or patients. 7. On 06/13/25 at 9:30 AM, upon entry to the facility, Surveyor #5 inspected the Day Room and noted the closed looped door closure and ligature risk. At that time, Staff #501 stated that patients were never in the room unsupervised and that the door was kept locked. At 9:50 AM, at the time the 6 patients were observed in the room unsupervised, Staff #501 verified the ligature point and that the staff were not monitoring the room. Item #2 Identification of Ligature Risk Based on observation and document review, the hospital failed to identify and then develop an appropriate ligature risk removal or mitigation plan in patient care areas. Failure to identify and develop plans to remove or mitigate ligature risks can result in patient harm and death related to suicide by hanging. Findings included: West 1 and West 2 Units 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. Review of the document showed the following: a. West 1 Unit i. Potential Area of Risk: “Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping.” b. West 2 Unit i. Potential Area of Risk: “Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping.” 2. On 06/12/25 at 9:59 AM, Surveyor #5 and the Director of Risk Management (Staff #501) inspected the West 2 Unit. Surveyor #5 noted closed-loop door closures open to the hallway near rooms #901, #902, #903, and #904. Surveyor #2 noted patients in rooms #901, #902, #903, and #904. Surveyor #5 noted staff in the hallway making every 15-minute rounds, but no continuous observation. Surveyor #5 asked Staff #501 about the mitigation plan for West 2 and West 1. 3. At the time of the review, Staff #501 verified that the West 1 and West 2 Units were mirror images of each other. Staff #501 stated that staff had a presence in the hallway, and she expected them to care for patients, not to watch door closures. 4. On 06/12/25, a review of the hospital’s ligature risk assessment showed that the hospital had not identified the closed-loop hinged door closures as a ligature risk or developed a plan to remove or mitigate the risk for West 1 or West 2 Units. South Unit 5. Document review of hospital’s ligature risk assessment effective date 1/29/25 showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. a. South Unit i. On 06/10/25 between the hours of 9:45 AM and 10:30 AM Surveyor #1 toured the south adolescent unit with the assistant chief operation officer (Staff #104). Surveyor #1 observed looped door enclosures at the entrance into the unit. 2 staff members were seated in front of the doors to monitor staff. Surveyor #1 reviewed the ligature risk assessment plan. The plan indicated that all exit doors have delayed egress door hardware installed where code requires. The risk assessment plan does not mention the ligature risk of the entrance door enclosures that are looped. Monroe 6. Document review of hospital’s ligature risk assessment effective date 1/29/25 showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. The document showed, “ Potential Area of Risk: “Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping and door closures, in necessary are mounted on the hall side.” 7. On 06/13/25 between the hours of 10:30 AM and 11:30 AM Surveyor #1 and Surveyor #10 inspected the Monroe Campus with the facility supervisor (Staff #105) and the assistant chief nursing officer (Staff #106). During the inspection, the surveyors observed the following: a. A hand sink in the “tub” room that had a partial shield which created a potential looped ligature risk, and it also had exposed overflow drain line under the sink. b. a. A looped door closures in the hallway monitored by staff, but not identified on the hospitals ligature risk plan as a potential area of risk. Staff #106 indicated that they have continuous monitoring of the door enclosures. 8. In an interview with Staff #105 regarding the patient hand sink in the “tub” room. Staff #105 indicated that the sink should have had a cover underneath the sink. This is congruent with the risk assessment plan for patient hand sinks. 4. On 06/13/25, a review of the hospital’s ligature risk assessment showed that the hospital had not identified the closed-loop drain line in the “Tub Room” as a ligature risk or developed a plan to remove/mitigate the risk. The hospital had not identified the close looped door closure in the hallway as a ligature risk or documented plan to remove/mitigate the risk with in the risk assessment. Item #3 Comprehensive Risk Assessment Based on document review and interview, the hospital failed to develop and implement ligature mitigation strategies for ligature risks identified in their 2025 Ligature Risk Assessment. Failure to develop and implement a complete Ligature Risk, Prevention, and Mitigation Plan can result in patient harm and death related to suicide by hanging. Findings included: 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed the following: a. East Unit i. Potential Area of Risk: Hallway Door Closures, if necessary, are mounted on the hall side. ii. Comment/finding: Yes iii. Risk Rating 3 iii. Mitigation Strategies: None identified Surveyor #5 found no evidence that the hospital developed a prevention or mitigation plan for the identified risks on the East Unit per the Risk Assessment document. 2. The review showed that there were inconsistencies in the completion of the risk document, including: a. East Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 5 sections/locations/areas of the document. b. West 1 Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 6 sections/locations/areas of the document. c. West 2 Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 8 sections/locations/areas of the document. d. North Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 5 sections/locations/areas of the document. e. Other Patient Areas: The risk rating was zero, but a mitigation plan was developed in 1 sections/locations/areas of the document. f. Monroe: Potential risks identified, and mitigation strategies identified, but no risk rating completed, or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 4 sections/locations/areas of the document. 3. On 06/13/25 at 8:00 AM, during an interview with the Chief Operating Officer (Staff #507) and the Director of Risk Management (Staff #501), Surveyor #5 reviewed the inconsistencies in the documentation of the hospital’s Risk Prevention and Mitigation Plan and observations of implementation of the plan including mitiagation plans not implemented, ligature risks not identified, ligature risks identified but with out a mitigation plan, risk ratings not completed, and conflicting documentation including plans when there was no risk identified. Staff #507 verified the inconsistencies and stated that the plan would be reviewed. .”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 38532 . Item #1 Ligature Risk Mitigation Based on observation, interview, and document review, the hospital failed to ensure that it implemented its ligature risk mitigation plan for ligature risks in the patient care area identified by the hospital. Failure to mitigate ligature risks can result in patient harm and death related to suicide by hanging. Findings included: 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed the following: a. North Unit i. Potential Area of Risk: Door Closures, if necessary, are mounted on the hall side. ii. Comment/finding: Yes iii. Mitigation Strategies: “Staff presence in hallways; hallway is under continual supervision.” b. Fairfax Everett Behavioral Health Hospital i. Potential Area of Risk: On-Unit Day Room and Group Room: Door closures, if necessary, are mounted on the hall side ii. Comment/finding: No-door closures mounted on the room side in South Consult room and both day rooms. iii. Mitigation Strategies: Continuous in-person monitoring anytime a patient is in this area. 2. On 06/10/25 at 10:08 AM, Surveyor #5 and the Nurse Manager (Staff #502) inspected Kirkland Campus North Unit. Surveyor #5 observed a hallway that contained 2 patient rooms (#138, a single patient room, and #139, a double patient room), as well as the Seclusion room. The main hallway connected to this hallway in a T shape. At the end of this hallway was a door (located between room #138 and #139 that opened to a courtyard.) Surveyor #5 noted that the door closure device that opened to the hallway was a closed-loop hinge. At the opposite end of the hallway near the nurses’ station, Surveyor #5 observed a double door where one door opened to this hallway, and one opened to the main hallway. Both door closure devices were the close-hinged type. Surveyor #5 observed the hallway for approximately 30 minutes and noted that there was no direct supervision of the hallway by staff. 3. During the interview with the Manager (Staff #501), the 2 hallway cameras were not monitored but can be reviewed if problems are identified. 4. On 06/13/25 at 9:30 AM, Surveyor #5, the Director of Risk (Staff #501), and an Assistant Administrator (Staff #503), inspected the physical environment for Fairfax Behavioral Health Hospital Everett. Surveyor #5 observed a closed-loop door closure device on the exit door by Room #708. Surveyor #5 noted 2 closed-loop door closures on the fire doors near room #713. Surveyor #5 observed the hallway for approximately 5 minutes and noted that there was no staff supervision of the hallway. At this time, Surveyor #5 requested information related to suicide precautions or suicide risk for the patients who were in rooms #709 and #713 at the time of the observation. 5. At the time of the review, Staff #501 verified that there was not a staff member providing continuous direct observation of the hallway with the ligature risks and stated that there were staff present in the area and that staff were doing rounds monitoring the patients. Staff #501 verified that the Patient in Room #708 at the time of the observation was on Suicide and Fall Precautions (Patient #501). 6. On 06/13/25 at 9:50 AM, Surveyor #5, the Director of Risk (Staff #501), and an Assistant Administrator (Staff #503), continued inspection of the physical environment for Fairfax Behavioral Health Hospital Everett. Surveyor #5 observed a Day Room near the entrance to the facility with 6 unsupervised patients inside the room. Surveyor #5 observed the 6 patients in the room for approximately 5 minutes. Surveyor #5 found no evidence that staff were observing the room or patients. 7. On 06/13/25 at 9:30 AM, upon entry to the facility, Surveyor #5 inspected the Day Room and noted the closed looped door closure and ligature risk. At that time, Staff #501 stated that patients were never in the room unsupervised and that the door was kept locked. At 9:50 AM, at the time the 6 patients were observed in the room unsupervised, Staff #501 verified the ligature point and that the staff were not monitoring the room. Item #2 Identification of Ligature Risk Based on observation and document review, the hospital failed to identify and then develop an appropriate ligature risk removal or mitigation plan in patient care areas. Failure to identify and develop plans to remove or mitigate ligature risks can result in patient harm and death related to suicide by hanging. Findings included: West 1 and West 2 Units 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. Review of the document showed the following: a. West 1 Unit i. Potential Area of Risk: “Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping.” b. West 2 Unit i. Potential Area of Risk: “Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping.” 2. On 06/12/25 at 9:59 AM, Surveyor #5 and the Director of Risk Management (Staff #501) inspected the West 2 Unit. Surveyor #5 noted closed-loop door closures open to the hallway near rooms #901, #902, #903, and #904. Surveyor #2 noted patients in rooms #901, #902, #903, and #904. Surveyor #5 noted staff in the hallway making every 15-minute rounds, but no continuous observation. Surveyor #5 asked Staff #501 about the mitigation plan for West 2 and West 1. 3. At the time of the review, Staff #501 verified that the West 1 and West 2 Units were mirror images of each other. Staff #501 stated that staff had a presence in the hallway, and she expected them to care for patients, not to watch door closures. 4. On 06/12/25, a review of the hospital’s ligature risk assessment showed that the hospital had not identified the closed-loop hinged door closures as a ligature risk or developed a plan to remove or mitigate the risk for West 1 or West 2 Units. South Unit 5. Document review of hospital’s ligature risk assessment effective date 1/29/25 showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. a. South Unit i. On 06/10/25 between the hours of 9:45 AM and 10:30 AM, Surveyor #1 toured the South unit with the assistant chief operation officer (Staff #104). Surveyor #1 observed looped door enclosures at the entrance into the unit. 2 staff members were seated in front of the doors to monitor staff. Surveyor #1 reviewed the ligature risk assessment plan. The plan indicated that all exit doors have delayed egress door hardware installed where code requires. The risk assessment plan does not mention the ligature risk of the entrance door enclosures that are looped. Monroe 6. Document review of hospital’s ligature risk assessment effective date 1/29/25 showed that the risk assessment is broken up into 4 categories that included identifying the risk, a comment on the risk, rating the risk and the mitigation strategies of the risk identified. The document showed, “Potential Area of Risk: Hallways, No wall or ceiling mounted hardware, brackets, or thermostats to provide opportunity for looping and door closures, in necessary are mounted on the hall side.” 7. On 06/13/25 between the hours of 10:30 AM and 11:30 AM, Surveyor #1 and Surveyor #10 inspected the Monroe Campus with the facility supervisor (Staff #105) and the assistant chief nursing officer (Staff #106). During the inspection, the surveyors observed the following: a. A hand sink in the “tub” room that had a partial shield which created a potential looped ligature risk, and it also had exposed overflow drain line under the sink. b. A looped door closures in the hallway monitored by staff, but not identified on the hospitals ligature risk plan as a potential area of risk. Staff #106 indicated that they have continuous monitoring of the door enclosures. 8. In an interview with Staff #105 regarding the patient hand sink in the “tub” room, Staff #105 indicated that the sink should have had a cover underneath the sink. This is congruent with the risk assessment plan for patient hand sinks. 9. On 06/13/25, a review of the hospital’s ligature risk assessment showed that the hospital had not identified the closed-loop drain line in the “Tub Room” as a ligature risk or developed a plan to remove/mitigate the risk. The hospital had not identified the close looped door closure in the hallway as a ligature risk or documented plan to remove/mitigate the risk with in the risk assessment. Item #3 Comprehensive Risk Assessment Based on document review and interview, the hospital failed to develop and implement ligature mitigation strategies for ligature risks identified in their 2025 Ligature Risk Assessment. Failure to develop and implement a complete Ligature Risk, Prevention, and Mitigation Plan can result in patient harm and death related to suicide by hanging. Findings included: 1. Document review of the hospital’s mitigation plan titled, “Fairfax Behavioral Health Kirkland- Environmental/Ligature Risk Assessment Prevention/Mitigation Plan,” dated 03/07/25,” showed the following: a. East Unit i. Potential Area of Risk: Hallway Door Closures, if necessary, are mounted on the hall side. ii. Comment/finding: Yes iii. Risk Rating 3 iii. Mitigation Strategies: None identified Surveyor #5 found no evidence that the hospital developed a prevention or mitigation plan for the identified risks on the East Unit per the Risk Assessment document. 2. The review showed that there were inconsistencies in the completion of the risk document, including: a. East Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 5 sections/locations/areas of the document. b. West 1 Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 6 sections/locations/areas of the document. c. West 2 Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 8 sections/locations/areas of the document. d. North Unit: Potential risks identified, and mitigation strategies identified, but no risk rating completed or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 5 sections/locations/areas of the document. e. Other Patient Areas: The risk rating was zero, but a mitigation plan was developed in 1 sections/locations/areas of the document. f. Monroe: Potential risks identified, and mitigation strategies identified, but no risk rating completed, or no risk was found, and the risk rating was zero, but a mitigation plan was developed in 4 sections/locations/areas of the document. 3. On 06/13/25 at 8:00 AM, during an interview with the Chief Operating Officer (Staff #507) and the Director of Risk Management (Staff #501), Surveyor #5 reviewed the inconsistencies in the documentation of the hospital’s Risk Prevention and Mitigation Plan and observations of implementation of the plan including mitigation plans not implemented, ligature risks not identified, ligature risks identified but without a mitigation plan, risk ratings not completed, and conflicting documentation including plans when there was no risk identified. Staff #507 verified the inconsistencies and stated that the plan would be reviewed. .”