Grant Memorial Hospital

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 40269 Based on document review, policy reviews, medical record reviews, observation, and staff interviews, it was determined staff failed to follow suicide policies and procedures in the Emergency Department (ED) and failed to implement a suicide observation/safety check policy to ensure patients at moderate or high risk for suicide are properly monitored as per the standard of care for suicidal patients. This failure has the potential to negatively impact all patients receiving care at the facility. (see tag C1006 and C1014) Cross reference §485.635(a) Standard: Patient Care Policies and §485.635(a)(3) The policies include the following: (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 40269 Based on policy review, medical record review, observation, and staff interviews, it was determined staff failed to follow suicide policies and procedures in the Emergency Department (ED) in eight (8) out of ten (10) medical records reviewed, patients 1, 2, 3, 4, 5, 6, 7, and 8. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled, “Suicide Risk Assessment and Intervention,” last reviewed 05/30/25. The policy states in part, “I. Purpose: To identify and assure safe handling of patients with potential for suicide risk. II. Policy: Suicide Risk Assessment and Intervention:... Moderate/High risk for suicide: the RN [Registered Nurse] in the ED [Emergency Department] will: a. Initiate a 1:1 [one to one] level of observation (float or call-in additional staff if needed). b. Notify the ED Practitioner of both the risk for suicide and its level (moderate, high). c. Place in room 1 [one] in the Emergency Room. Place in a room nearest to the nurse’s station in the inpatient/observation departments. If a room is unavailable, conduct an environmental risk assessment to identify and remove features in the physical environment that could potentially be used for harm. d. Have patient to remove all items of clothing/personal items and place them in a hospital gown. Remove personal items from the room. e. Patient may have cell phone or tablet. f. Meals are prepared on Styrofoam trays with finger foods. Plasticware are provided upon nursing/physician request. f. No visitors g. Make telepsych consultation arrangement as ordered by the physician. h. Order Suicide precautions. i. Schedule 1:1 [one to one] sitter to be with the patient at all times. j. Directly address suicidality in the treatment and discharge plan. k. Provide for counseling and follow-up care upon discharge. Telepsych; A. Complete and document a complete psychiatric evaluation. B. Document the level of observation required and justification. C. Review Plan of Care and recommend specific interventions to manage risk of harm to self or others. D. Make the decision if the patient can be discharged with outpatient follow-up or placed in a behavioral health facility ...” A policy was reviewed titled, “Patient Rights and Responsibilities,” last reviewed 01/20/26. The policy states in part, “...Procedure: Patients in WVUHS [West Virginia University Health System] hospitals have the right to:...- Receive care in a safe environment free from all forms of abuse, neglect or mistreatment ...” A medical record review was conducted for patient 1. The patient presented to the facility’s Emergency Department (ED) on 01/15/26 via Emergency Medical Services (EMS) with a complaint of suicidal ideations, and ingesting twenty-one (21) tablets of a prescribed medication. The patient was placed into ED room one (1). A “Suicide Monitoring/Prevention” note by staff 9 at 3:49 p.m. states, “ASQ [Ask Suicide-Screening Questions] Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes.Precautions: Suicide Precautions - Moderate. Suicide Precautions Status- Moderate: Initiated Suicide Preacautions: Suicide Precautions Status- Moderate: Initiated. Safety Management: Enhanced Safety Measures: family to remain at bedside.” At 3:50 p.m. a note by staff 9 states, “Safety Assessment- Safety Factors: bed in low position; wheels locked;call light in reach; lD [identification] band on; side rails raised on one [1] side only.” An “ED Primary Note” on 01/15/26 beginning at 4:13 p.m. by staff 4 states in part, “...1615 [4:15 p.m.] EKG [electrocardiogram], interpreted by me,... 1654 [4:54 p.m.] [Name] from tele psych [telepsychiatry] called here, and states that if it is clear that [he/she] is depressed and suicidal and needs admission, there is no question to be answered here, and [he/she] does not need evaluation by a psychiatrist prior to admission. Our staff is working toward placement now. 1842 [6:42 p.m.] Family has signed paperwork to seek admission for inpatient psychiatric hospitalization. [He/she] is medically cleared. Continuing the process of finding placement. 2015 [8:15 p.m.] A charge uses reviewing the application at 1 [one] of the psychiatric facilities. Fri [friday] Jan 16, 2026 [01/16/26]: 0749 [7:49 a.m.] No symptoms overnight, calm and compliant. Signed out to the care of [staff 3] at 8:00 a.m. with psychiatric placement pending ...Clinical impression: Suicide attempt (Primary)...” Vital signs were documented at 6:45 p.m., 9:33 p.m., 9:55 p.m., 11:26 p.m., and on 01/16/26 at 1:27 a.m., 4:55 a.m., 7:05 a.m., 9:15 a.m., 10:15 a.m., 10:45 a.m., 11:00 a.m., 11:15 a.m., 11:30 a.m., 11:32 a.m., 11:33 a.m., and 11:45 a.m. The patient was transferred from the facility on 01/16/26 at 12:35 p.m. May it be noted, no additional nurse’s notes or nursing documentation was noted in the patient’s medical record. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient, as it states the family remained at bedside. No physician orders for suicide precautions were noted. A record review was conducted for patient 2. The patient presented to the facility’s ED on 01/05/26 at 11:34 a.m. with a complaint of suicidal ideation. A “Suicide Monitoring/Prevention” note at 11:49 a.m. by staff 9 states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes. Precautions: Suicide Precautions - Moderate. Suicide Precautions Status- Moderate: Initiated. Suicide Preacautions: Suicide Precautions Status- Moderate: Initiated. Safety Management: Enhanced Safety Measures: enhanced safety check; family to remain at bedside.” At 12:05 p.m. Orders were placed- “Precaution - SUICIDE PRECAUTIONS - MODERATE RISK” Vital signs were documented at 11:50 a.m., 3:41 p.m., 5:58 p.m. A “Psychiatry Consult” at 2:41 p.m. states in part, “...- Precautions: Moderate risk suicide precautions -Disposition: Appropriate for acute psychiatric inpatient admission, Rationale: Mood disorder symptoms affecting acute safety risk, Suicidal Ideation, Exacerbation of psychiatric disorder with safety concern, New or acute psychiatric decompensation, and Failure of lower level of care ...” At 2:35 p.m. a “Suicide Monitoring/Prevention” note states, “Precautions: Suicide Precautions Status- Moderate: Continued. Suicide Preacautions: Suicide Precautions Status- Moderate: Continued” The patient was transferred from the facility at 6:34 p.m. May it be noted, no additional nurse’s notes or nursing documentation was noted in the patient’s medical record. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient, as it states the family remained at bedside. A medical record review was conducted for patient 3. The patient presented to the facility’s ED on 01/03/26 at 5:22 p.m. with intentional overdose and suicidal ideation. A “Suicide Monitoring/Prevention” note at 5:25 p.m. states in part, “...Calculated Risk Score: Imminent/High Risk, Suicide Precautions: High, Enhanced Safety Measures: enhanced safety check;1 to 1 [one to one] observation in place (constant visual/constant visual touch); family educated on 1 to 1 [one to one] process; patient educated on 1 to 1 [one to one] process; mitigation of ligature and environmental risks; ligature and environmental risk assessment reviewed and completed; search and securement completed.” Orders were placed at 5:26 p.m. stating, “Precaution - SUICIDE PRECAUTIONS - HIGH RISK Nursing - PATIENT MONITORING CONTINUOUS 1 [one] STAFF: 1 [one] PATIENT.” A psychiatry consult on 01/03/26 at 10:23 p.m. states in part, “...ASQ Screening Results: Ask Suicide-Screening Questions Calculated Risk Score: Imminent/High Risk ...Overall Level of Acute Suicide Risk: high. Interventions: Please follow hospital policies congruent with suicide risk level indicated including observation status.” Vital signs were documented every fifteen (15) to thirty (30) minutes throughout the patient’s stay. A safety assessment was documented at 5:38 p.m., and on 01/07/26 at 2:30 a.m. and 4:18 a.m. A “Quick Updates” note at 9:55 p.m. states, “Updates: Rounded on patient, no further needs noted at this time; Patient is resting comfortably; Family at bedside; Family updated; Patient identified” The documentation reflects the family remained at bedside, and there is no documentation the staff was on one to one (1:1) observation with the patient. The patient was transferred from the facility on 01/04/26 at 9:02 a.m. A review was conducted of patient 4’s medical record. The patient presented to the facility’s ED on 01/06/26 at 4:20 p.m. with a complaint of suicidal ideations. A “Suicide Monitoring/Prevention” note at 4:32 p.m. states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes. Ask Suicide-Screening Questions 1. In the past few weeks, have you wished you were dead? : Yes ! 2. ln the past few weeks, have you felt that you or your family would be better off if you were dead?: Yes ! 3. ln the past week, have you been having thoughts about killing yourself?: Yes ! 4. Have you ever tried to kill yourself?: Yes ! lf yes, how did you try to kill yourself?: Strangle myself with a sheet lf yes, when did you try to kill yourself?: Last year while in jail. 5. Are you having thoughts of killing yourself right now?: Yes ! lf yes, describe your thoughts of killing yourself right now:: Stab myself or hang myself or run out into traffic. Precautions: Suicide Precautions - High. Suicide Precautions Status - Hlgh: Initiated Suicide Preacautions: Suicide Precautions Status - High: Initiated. Safety Management Enhanced Safety Measures: enhanced safety check; family educated on 1 to 1 [one to one] process; ligature and environmental risk assessment reviewed and completed; mitigation of ligature and environmental risks; placed in a safety gown; patient educated on 1 to 1 [one to one] process; safe room utilized.” A “Psychiatry Consult” on 01/06/26 at 5:35 p.m. states in part, “...Safety Screening: Summary: At this time, the patient poses an elevated acute risk of harm ... Plan/Recommendations:... - Precautions: High risk suicide precautions.” Vital signs were documented at 4:30 p.m., 9:54 p.m. and on 01/07/26 at 4:17 a.m., 6:41 a.m., 1:30 p.m., 3:21 p.m., 5:07 p.m., 8:46 p.m., on 01/08/26 at 3:07 a.m. 11:40 a.m., at 3:52 p.m. A “Tech [patient care technician] Rounding” note on 01/07/26 at 2:30 a.m. states, “Tech Rounding Documentation: Hourly rounds completed: Pt [patient] observed to be sleeping Activity Assistance Provided: independent. Diet/Feeding Assistance: none. Safety Factors: bed in low position; wheels locked; call light in reach; lD band on; side rails raised on one side only.” An “ED Notes” at 4:19 a.m. states, “Patient up to the bathroom. Vitals taken. Warm blanket given.” A “Adult Assessment” was documented on 01/07/26 at 8:12 a.m., and 2:52 p.m. A “ED Notes” at 12:13 p.m. states, “Meal tray given.” A “Quick Updates” note on 01/08/26 at 4:00 a.m. states, “Updates: Rounded on patient, no further needs noted at this time; Patient is resting comfortably.” On 01/08/26 at 11:23 a.m. a “Suicide Monitoring/Prevention” note states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No Patient has active suicide thoughts or attempt: Yes. Ask Suicide-Screening Questions 1. ln the past few weeks, have you wished you were dead? : Yes ! 2. ln the past few weeks, have you felt that you or your family would be better off if you were dead?: Yes ! 3. ln the past week, have you been having thoughts about killing yourself?: Yes ! 4. Have you ever tried to kill yourself?: Yes ! 5. Are you having thoughts of killing yourself right now?: Yes ! Precautions: Suicide Precautions Status - High: Continued. Suicide Preacautions: Suicide Precautions Status - High: Continued.” Orders were placed on 01/08/26 at 11:23 a.m. stating, “Precaution - SUICIDE PRECAUTIONS - HIGH RISK, Nursing - PATIENT MONITORING CONTINUOUS 1 [one] STAFF:1 [one] PATIENT.” Suicide risk was re-assessed at 1:00 p.m. and 3:32 p.m. to continue to be high. ED “Nurses Notes” with the patient’s current status was documented on 01/07/26 at 8:15 a.m., 9:37 a.m., 9:41 a.m., 12:54 p.m., and 2:51 p.m. May it be noted, there was no additional documentation. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient. The patient was transferred from the facility on 01/08/26 at 4:14 p.m. A medical record was reviewed for patient 5. The patient presented to the facility’s ED on 01/20/26 at 6:32 p.m. for suicidal ideations. May it be noted- patient 4 and patient 5 are the same person. A “Suicide Monitoring/Prevention” note at 6:45 p.m. states in part, “...Calculated Risk Score: Imminent/High Risk, Precautions Suicide Precautions - Moderate, Suicide Precautions Status- Moderate Initiated, Enhanced Safety Measures: enhanced safety check; placed in a safety gown;safe room utilized.” A “Safety Assessment” was documented at 6:46 p.m. Vital signs were documented at 6:42 p.m., 6:46 p.m., 10:29 p.m., and on 01/21/26 at 3:26 a.m., 6:25 a.m., and 8:12 a.m.. A “Psychiatric Evaluation” note on 01/20/26 at 9:35 p.m. states in part, “...Overall Level of Acute Suicide Risk: high, Interventions: Please follow hospital policies congruent with suicide risk level indicated including observation status ...” The patient was transferred from the facility on 01/21/26 at 8:20 a.m. May it be noted, no additional nurse’s notes or nursing documentation was noted in the patient’s medical record. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient. No physician orders for suicide precautions were noted. A medical record was reviewed for patient 6. The patient presented to the facility’s ED on 01/28/26 at 12:49 p.m. for suicidal ideations. A “Suicide Monitoring/Prevention” assessment was documented at 12:58 p.m. and states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes. Precautions: Suicide Precautions - Moderate. Suicide Precautions Status- Moderate: Initiated. Suicide Precautions Suicide Precautions Status- Moderate: Initiated. Safety Management: Enhanced Safety Measures: safe room utilized.” Vital signs were documented at 12:55 p.m., 1:05 p.m., 5:56 p.m., and 9:06 p.m., and on 01/29/26 at 5:13 a.m. A “Psychiatric Evaluation” on 01/28/26 at 8:43 p.m. states in part, “...Assessment: Primary Psychiatric Diagnosis: Major Depressive Disorder, recurrent, severe ASQ Screening Results: Ask Suicide-Screening Questions Calculated Risk Score: Imminent/High Risk ...lnterventions: Please follow hospital policies congruent with suicide risk level indicated including observation status ...” An “ED Note” on 01/28/26 at 10:00 p.m. states, “Rounded on pt, medicated as ordered. Pt resting comfortably in bed, warm blanket provided and no needs expressed at this time.” An “ED Note” on 01/29/26 at 1:28 a.m. states, “Patient is asleep and resting comfortably.” An “ED Note” on 01/29/26 at 4:16 a.m. states, “Pt resting quietly in bed, no acute distress noted.” The patient was transferred from the facility on 01/29/26 at 8:54 a.m. May it be noted, no additional nurse’s notes or nursing documentation was noted in the patient’s medical record. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient. No physician orders for suicide precautions were noted. A medical record was reviewed for patient 7. The patient presented to the facility’s ED on 02/09/26 at 5:32 p.m. for chest pain. During the cardiac workup, the patient endorsed suicidal ideations. A “Suicide Monitoring/Prevention” assessment was documented at 6:23 p.m. and states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes. Precautions: Suicide Precautions - Moderate. Suicide Precautions Status- Moderate: Initiated. Suicide Preacautions: Suicide Precautions Status- Moderate: Initiated. Safety Management: Enhanced Safety measures: enhanced safety check; family educated on 1 to 1 [one to one] process.” At 6:25 p.m. orders were placed stating, “Precaution - SUICIDE PRECAUTIONS - HIGH RISK. Nursing - PATIENT MONITORING CONTINUOUS 1 [one] STAFF :1 [one] PATIENT.” A “ED Primary Note” beginning on 02/09/26 by staff 4 states in part, “...Tue [Tuesday] Feb 10, 2026: 0810 [8:10 a.m.] Signed out to me at 8:00 a.m. from Dr. [name]. This is a 56 [fifty-six] -year-old [gender] who was initially complaining of chest discomfort that started yesterday in which is resolved at this time. [His/her] workup was unremarkable. When preparing for discharge, [he/she] complained of alcohol abuse and suicidal ideation without a plan. [He/she] states [he/she] typically drinks about 10 [ten] beers a day. [He/she] is not going through any withdrawal symptoms at this time. [He/She] was evaluated by tele psych, recommending inpatient care. The patient is amenable to that plan. [He/she] has eaten breakfast already. On review of laboratory tests, [he/she] appeared to have a degree of acidosis, and negative troponins x3 [times three]. I am repeating his BMP [basic metabolic panel] this morning. Placement in inpatient psychiatric care is pending. 0832 [8:32 a.m.] Medically cleared for psychiatric placement ...” A “Suicide Monitoring/Prevention” assessment was documented at 9:00 p.m. and states, “Precautions: Suicide Precautions - High. Suicide Precautions Status- Moderate: Continued. Suicide Precautions Status - High: Continued. Suicide Preacautions. Suicide Precautions Status- Moderate: Continued. Suicide Precautions Status - High: Continued. Safety Management: Enhanced Safety Measures: enhanced safety check; 1 to 1 [one to one] observation in place (constant visual/constant visual touch); ligature and environmental risk assessment reviewed and completed; placed in a safety gown; patient educated on 1 to 1 [one to one] process; safe room utilized; search and securement completed.” A “Suicide Monitoring/Prevention” assessment was documented at 9:06 p.m. and states, “ASQ Screening Readiness (Suicide Risk Screening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: Yes. Ask Suicide-Screening Questions 1. In the past few weeks, have you wished you were dead?: Yes ! 2. In the past few weeks, have you felt that you or your family would be better off if you were dead?: Yes ! 3. ln the past week, have you been having thoughts about killing yourself?: Yes ! 4. Have you ever tried to kill yourself?: No 5. Are you having thoughts of killing yourself right now?: Yes ! lf yes, describe your thoughts of killing yourself right now: Patient does not have a plan at this time. Precautions: Suicide Precautions Status- Moderate: Initiated. Suicide Precautions Status - High: Initiated. Suicide Precautions Status- Moderate: Initiated. Suicide Precautions Status - High: Initiated. Safety Management. Enhanced Safety Measures: constant visual- group setting; safe room utilized.” A “Consult” note on 02/09/26 at 9:37 p.m. states in part, “...Overall Level of Acute Suicide Risk: high. Interventions: Please follow hospital policies congruent with suicide risk level indicated including observation status...” An “ED Note” on 02/09/26 at 9:48 p.m. states, “Patient moved to room 1 [one], and placed in a gown and non-skid socks. Patient’s personal belongings placed in a green patient belonging bag and placed in the nurses station.” Suicide precautions were evaluated by the RN, and continued to be high at 10:30 p.m., and on 02/10/26 at 12:33 a.m., 2:30 a.m., 4:41 a.m., 6:30 a.m., 8:01 a.m., 10:15 a.m., The patient was observed in the ED on 02/10/26 at 9:00 a.m. to be in ED Room One (1) with no staff present at bedside. There is no documentation in the patient’s record that staff remained at bedside. The patient remained in the ED at the time of survey. A medical record was reviewed for patient 8. The patient presented to the facility’s ED on 12/10/25 at 9:47 a.m. for suicidal ideations. A “Suicide Monitoring/Prevention” assessment was documented at 10:02 a.m. and states, “ASQ Screening Readiness (Suicide Risk Sceening) Do you need to defer this screening at this time?: No. Patient has active suicide thoughts or attempt: yes. Precautions: Suicide Precautions - Moderate. Suicide Precautions Status- Moderate: Initiated. Suicide Preacautions: Suicide Precautions Status- Moderate: Initiated. Safety Management: Enhanced Safety Measures: family to remain at bedside.” A “Psychiatry Consult” at 11:50 a.m. states in part, “...Ask Suicide Screening Questions Calculated Risk Score: Imminent/High Risk ...Safety Screening: Summary: At this time, the patient poses an elevated acute risk of harm ...- Precautions: High risk suicide precautions ...” Vital Signs were documented at 10:00 a.m., 1:41 p.m., and 5:45 p.m. A Safety Assessment was documented at 10:06 a.m. A “ED Note” at 5:02 p.m. states, “Patient is currently sleeping at this time. Will obtain vitals and offer meal tray when [he/she] wakes up.” The patient was transferred from the facility at 7:00 p.m. May it be noted, no additional nurse’s notes or nursing documentation was noted in the patient’s medical record. There is no evidence in the patient’s medical record that a one to one (1:1) staff was assigned to the patient, as it states the family remained at bedside. There are no physician orders for suicide precautions. An observation was conducted in the facility ED on 02/10/26 at 8:40 a.m. accompanied by staff 2. During the observation, patient 7 was noted to be in Room 01. No staff was present in the room with patient 7. The patient was noted to have cardiac monitoring wires on (his/her) chest. A large fan was on the floor, plugged in, but not turned on. Staff 2 explained the patient was just awaiting transfer. Staff 2 explained the fans are placed upon patient request, this patient was being observed from the nurses station, and the door would remain open. A telephone interview was conducted with staff 3 on 02/09/26 at 1:37 p.m. Regarding patients with suicide precautions, staff 3 states, “We have a bed, it is room one [1]. It is in proximity to the nurses’ station. Based on the patient’s suicide risk, whether it’s high, moderate, or low, we would adjust our observation accordingly. For pediatric patients, we determine if they are in close proximity to the nurses station in room one [1] and we have the family stay with them. We have regular check-ins based on the risk of the patient. I don’t know about documentation. There would be check-ins, but I’m not sure if it is documented. If the patient has a sitter, then that’s continuous eyes on. We determine the need for a sitter based on a case-by-case basis. If the patient is a minor, then the family stays with the patient.” A telephone interview was conducted with staff 4 on 02/09/26 at 2:00 p.m. Regarding patient 1, staff 4 states in part, “In this case, since the patient was on suicide precautions, there would be an adult in the room with [him/her], since [he/she] was a minor. We also put them into room one [1], right by the nurses’ station. [He/she] would also have changed into a gown and [his/her] personal belongings taken. I’m not exactly sure what the policy dictates in regards to safety checks and documentation. The patient would be on an EKG monitor which would let us know if anything was happening. Nursing or the physician can order and implement suicide precautions. In this case, since it was a child the family would stay with a patient and nursing would educate the family about one-on-one [1:1] precautions.” Regarding suicide precautions, staff 4 states, “In the case of a suicidal patient, each case is dealt with accordingly based on the situation.” A telephone interview was conducted with staff 5 on 02/09/26 at 2:30 p.m. Regarding suicide precautions, staff 5 states, “The precautions in place depend on what the patient is doing. I know we close the garage door and shut off access to supplies. I do not know how often you have to document. I know we just constantly check on the patient when we walk up and down the hall. If the patient is a minor, then the family has to stay with them, so we wouldn’t stay in the room.” An interview was conducted with staff 6 on 02/09/26 at 3:12 p.m. Regarding suicide precautions, staff 6 states, “If the patient is a minor, then the family is the one that stays with them. The doctor has a conversation with the family about the suicide precautions. Nursing or the PCT [patient care technician] can have a conversation with the family about coming to get the staff if they need to leave for any reason. We don’t tell them they can’t sleep. We can visualize into the room from the nurses station, and the patients are always on a cardiac monitor. If the patient is an adult, we take their things and make sure they’re in the room closest to the nurses station. We check on them every hour and get their vital signs every hour. If the provider feels the patient needs a one to one [1:1] then they place the order. The sitter would just watch the patient and there’s no documentation done. The nurse can document on the quick updates, or in the nurses notes. We would just document if they needed anything and what they are doing.” An interview was conducted with staff 8 on 02/09/26 at 3:35 p.m. Regarding suicide precautions, staff 8 states, “Typically we do document checks hourly, we would say things like the patient is resting or sleeping, and ask if they need anything. The suicide precautions are initially initiated during triage. The triage nurse will have the patient get into a gown, and remove everything out of the room or place the patient in room one [1] and take the patient’s belongings. It would depend on the situation if a one-to-one [1:1] was ordered or not. In this case, it is our policy, since the patient is a minor, to have family with them at all times. We tell them if they need a break to let us know so we can have someone set with them. As long as the family is not the one [1] who causes the issue they can stay. If a family falls asleep, it would not matter because the patient is in a room across from the nurses’ station and we leave the door open so we can see in. The physician is the one who makes the decision if the family can stay with a patient. The family can stay with an adult patient if they’re not the one causing the issue, and the physician deems it appropriate. Nursing or physicians can implement suicide precautions if the patient comes in for that, there may not be an order actually placed for that precaution. The physician would have to place an order for a one-to-one [1:1] sitter. The sitter could be security or staff. If it is nursing staff, they could possibly document it as a safety check in Epic, but there’s no requirement for that. If it’s security, they wouldn’t be documenting anything. There is a suicide precautions flow sheet in Epic that we can document under. I do not know what the document requirements are.” An interview was conducted with staff 9 on 02/09/26 at 3:47 p.m. Regarding patient 1, staff 9 states in part, “I remember there was a [parent] there with a patient when [he/she] initially came, and then a [another parent] came after. We put [him/her] on a cardiac monitor, and put [him/her] into room one [1]. We lock down the room because there’s like a door that you can close and latch to prevent access to supplies. The patient’s family would stay with [him/her], that’s the policy since [he/she] was fourteen [14]. We make sure [he/she] takes off all [his/her] clothing except [his/her] underwear, and puts a gown on. The patient’s belongings are taken. Anything that can harm the patient has to be removed. We do not take anything from the family however. The family has to stay with them because the patient is a minor. If they need relief then staff is available to take their place but they have to stay with them. I’m not sure what the nurse would do in this case if the family fell asleep.” Regarding suicide precautions, staff 9 states, “We don’t have special safety checks for suicide patients, all patients get hourly rounding. We don’t necessarily document them hourly however. If the family does stay with a patient, whether they are a minor or an adult, I’ve never been told to take the belongings from the family. The staff is supposed to keep an eye on the patient but I’m not sure of the documentation requirements. We keep an eye on them by placing them in room one [1] which is across from the nurses station. We also look in the room when we walk up and down the halls.” An interview was conducted with staff 2 on 02/10/26 at 9:00 a.m. Regarding patient 1, staff 2 states in part, “In this case, since the patient was a minor, they would be told during triage that the family has to stay with the patient. That’s our process. Unless the parent is the actual issue, the patients are always more comfortable with a parent. If the parent was the issue, we would ask if any other family is available, and if not we would have staff sit with the patient. It is not a policy for the parents to stay with minor patients, it is a protocol. Our protocol states if the patient is a minor, then the parent or guardian has to stay with them. Again, this is not in writing anywhere. If the patient’s family would need a break, they need to tell us so they can go have a break. If the patient’s family would be sleeping in the room when we go to check on the patient, we would wake them up. We would check on the patient every hour. We don’t necessarily document that anywhere. We do not check the parents’ belongings. The whole reason the parents stay is they are responsible to let us know if something happens. We tell them in triage that someone has to stay, and they can tell staff if they need to take a break. The triage nurse and the physician can make the decision on who is appropriate to stay.” Regarding patient 7, staff 2 states, “This patient initially came in for chest pain then had suicidal ideations. [He/she] has been fine with us, cooperative, and is adjacent to the nurses’ station so [he/she] is in line of sight.” Staff 2 was not aware of the wording in the policy for suicide precautions. Staff 2 explained since the family sits with the patients that are minors, that would count as a sitter. An interview was conducted with staff 1 on 02/10/26 at 11:00 a.m. Regarding the process, staff 1 states, “We are going to evaluate our suicide policy and change it accordingly. The patient that you saw in the ED now has a one-to-one [1:1] sitter. We are working with the ED medical director on this process. We found a system policy that says it’s provider discretion if the patient gets a sitter. We’re going to have a discussion and evaluate what we are going to implement.””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. This Standard is not met as evidenced by: 40269 Based on document review, policy review, and staff interviews, it was determined staff failed to implement a suicide observation/safety check policy to ensure patients at moderate or high risk for suicide are properly monitored as per the standard of care for suicidal patients. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: An article was reviewed titled, “Managing Suicidal Patients in the Emergency Department,” dated 02/2017 from the “Annals of Emergency Medicine.” The article states in part, “...SAFETY PRECAUTIONS: Patients being evaluated for suicidal thoughts or behaviors should not be allowed to leave the ED until the evaluation is complete and should be protected from self-harm while in the ED. Typically, this includes placing the patient in a private room without access to potentially dangerous objects (e.g., belts, shoelaces, or sharp medical instruments). Mechanical or chemical restraints can be traumatic to the patient and impair rapport, so ED providers should first try to verbally de-escalate agitated patients (for example, by having extra personnel step out of sight and by engaging in collaborative, respectful conversation). Providers should advocate for a written ED policy concerning care of suicidal patients to clarify pathways and support provider actions, including use of constant observation, personal searches by security staff, or restraints ...” A policy was reviewed titled, “Suicide Risk Assessment and Intervention,” last reviewed 05/30/25. The policy states in part, “I. Purpose: To identify and assure safe handling of patients with potential for suicide risk. II. Policy: Suicide Risk Assessment and Intervention: DEFINITIONS: Suicide: Death caused by self-directed injurious behavior with an intent to die as a result of the behavior. -Suicide attempt: A non-fatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior; might not result in injury. ·Suicidal ideation: Thinking about, considering, or planning suicide. III. Procedure 1. Complete suicide assessment that includes questions about plans, risk factors, protective factors, triggers, and warning signs for suicidal ideation, homicidal ideation, and self -injurious behavior. a. Determine if the patient is low, moderate, or high risk. Low risk for suicide the RN will: a. Notify the Practitioner of both the risk and its level (low). b. Collaborate with the physician, the level observation appropriate for the patient. c. Place in room 1 [one] in the Emergency Room. Place in a room nearest to the nurse’s station in the inpatient/observation departments. If a room is unavailable, conduct an environmental risk assessment to identify and remove features in the physical environment that could potentially be used for harm. d. Have patient to remove all items of clothing/personal items and place in a hospital gown. Remove personal items from the room. e. Schedule 1:1 [one to one] sitter to remain with the patient at all times. f. Patient may have cell phone or tablet. g. Meals are prepared on Styrofoam trays with finger foods. Plastic ware are provided upon nursing/physician request. g. No visitors h.Document the plan to mitigate the risk for suicide in the EMR. i. Document assessment and observations j.Collaborate with [name] Peer Recovery to be seen in the ED and/or follow-up on an outpatient basis. k. Provide Suicide Prevention Information. Moderate/High risk for suicide the RN in the ED will: a. Initiate a 1:1 [one to one] level of observation (float or call-in additional staff if needed). b. Notify the ED Practitioner of both the risk for suicide and its level (moderate, high). c. Place in room 1 [one] in the Emergency Room. Place in a room nearest to the nurse’s station in the inpatient/observation departments. If a room is unavailable, conduct an environmental risk assessment to identify and remove features in the physical environment that could potentially be used for harm. d. Have patient to remove all items of clothing/personal items and place in a hospital gown. Remove personal items from the room. e. Patient may have cell phone or tablet. f. Meals are prepared on Styrofoam trays with finger foods. Plastic ware are provided upon nursing/physician request. f. No visitors g Make telepsych consultation arrangement as ordered by the physician. h. Order Suicide precautions. i. Schedule 1:1 sitter to be with the patient at all times. j. Directly address suicidality in the treatment and discharge plan. k. Provide for counseling and follow-up care upon discharge. Telepsych; A. Complete and document a complete psychiatric evaluation. B. Document the level of observation required and justification. C. Review Plan of Care and recommend specific interventions to manage risk of harm to self or others. D. Make the decision if the patient can be discharged with outpatient follow-up or placed in a behavioral health facility. Discharge: EDUCATION: All patients who are admitted to the psychiatric service, or are being treated for psychiatric, emotional or behavior disorders/complaints in identified locations will be given the following information and instructions in WRITTEN form upon discharge: “If you feel unsafe or feel that you might harm yourself or others you can: A. Call 1-800-273-8255 for the National Suicide Prevention Lifeline B. Call 911 or go to your nearest emergency room.” The following patient educational sheets may be printed for the patient and added to the discharge information within the EMR ...” A telephone interview was conducted with staff 3 on 02/09/26 at 1:37 p.m. Regarding patients with suicide precautions, staff 3 states in part, “We have regular check-ins based on the risk of the patient. I don’t know about documentation. There would be check-ins, but I’m not sure if it is documented.” A telephone interview was conducted with staff 4 on 02/09/26 at 2:00 p.m. Regarding patient 1, staff 4 states in part, “I’m not exactly sure what the policy dictates in regards to safety checks and documentation. The patient would be on an EKG monitor which would let us know if anything was happening. Nursing or the physician can order and implement suicide precautions. In this case, since it was a child the family would stay with a patient and nursing would educate the family about one-on-one [1:1] precautions.” Regarding suicide precautions, staff 4 states, “In the case of a suicidal patient, each case is dealt with accordingly based on the situation.” A telephone interview was conducted with staff 5 on 02/09/26 at 2:30 p.m. Regarding suicide precautions, staff 5 states, “I do not know how often you have to document. I know we just constantly check on the patient when we walk up and down the hall.” An interview was conducted with staff 6 on 02/09/26 at 3:12 p.m. Regarding suicide precautions, staff 6 states in part, “We check on them every hour and get their vital signs every hour. If the provider feels the patient needs a one to one [1:1] then they place the order. The sitter would just watch the patient and there’s no documentation done. The nurse can document on the quick updates, or in the nurses notes. We would just document if they needed anything and what they are doing.” An interview was conducted with staff 8 on 02/09/26 at 3:35 p.m. Regarding patient 1, staff 8 states in part, “I reviewed my notes and I did not document anything so it must have been a busy night.” Regarding suicide precautions, staff 8 states, “Typically we do document checks hourly, we would say things like the patient is resting or sleeping, and ask if they need anything ... The physician would have to place an order for a one-to-one [1:1] sitter. The sitter could be security or staff. If it is nursing staff, they could possibly document it as a safety check in Epic, but there’s no requirement for that. If it’s security, they wouldn’t be documenting anything. There is a suicide precautions flow sheet in Epic that we can document under. I do not know what the document requirements are.” An interview was conducted with staff 9 on 02/09/26 at 3:47 p.m. Regarding suicide precautions, staff 9 states in part, “We don’t have special safety checks for suicide patients, all patients get hourly rounding. We don’t necessarily document them hourly however...The staff is supposed to keep an eye on the patient but I’m not sure of the documentation requirements. We keep an eye on them by placing them in room one [1] which is across from the nurses station. We also look in the room when we walk up and down the halls.” An interview was conducted with staff 2 on 02/10/26 at 9:00 a.m. Regarding patient 1, staff 2 states in part, “We would check on the patient every hour. We don’t necessarily document that anywhere.”Staff 2 was not aware of the wording in the policy for suicide precautions. Staff 2 explained since the family sits with the patients that are minors, that would count as a sitter. An interview was conducted with staff 1 on 02/10/26 at 11:00 a.m. Regarding the process, staff 1 states in part, “We are going to evaluate our suicide policy and change it accordingly. We are working with the ED medical director on this process. We’re going to have a discussion and evaluate what we are going to implement.””