**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure environmental hazards were removed from the resident's room after a suicide attempt for 1 of 2 residents reviewed for accidents/hazards. (Resident 5) The immediate jeopardy began on June 6, 2023 when Resident 5 wrapped a bed remote cord around his neck and the facility failed to remove the hazard from his room. The administrator and regional nurse consultant were notified of the immediate jeopardy on July 26, 2023 at 4:50 P.M. The immediate jeopardy was removed on July 27, 2023, but noncompliance remained at the lower scope and severity level of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Finding includes: A record review for Resident 5 was completed on 7/26/2023 at 9:02 A.M. Diagnoses included, but were not limited to: Friedreich's Ataxia (disease which causes progressive nervous system damage), anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, single episode, moderate, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement and paraplegia unspecified. During an observation, on 7/26/2023 at 10:47 A.M., the resident's bed was in a high position from the floor. During an observation on 7/26/2023 at 3:34 P.M., the bed remote cord was not fastened to the bed rail with a zip tie, only the call light was. The resident had full access to the bed remote cord hanging from the assist/bed rail. The bed was also not in a low position, but up high. A Progress Note, dated 6/6/2023 at 4:24 P.M., indicated .CNA came by nurse's station stating that resident had attempted to strangle himself with his bed cord. CNA went and got Social Services. Nurse went in and spoke with resident. Resident was tearful. Nurse asked Resident if he was trying to harm himself and he became even more tearful while shaking his head yes. Social Worker came in to speak with Resident. A Progress Note, dated 6/6/2023 at 5:13 P.M., indicated .Late Entry: SS [Social Service] visited with [Resident 5] today due to reports of increased behaviors. [Resident 5] presented very emotional and became tearful several times during conversation. SS talked with him about putting cord around his neck. He expressed he was not trying to kill self. he just needed help from staff and he was frustrated. SS explained to [Resident] that when he does things like that he runs the risk of being sent to inpatient psyche stay. He expressed he did not want he wants. SS discussed alternate ways to get staff assistance. SS allowed him time to express his feelings and offered comfort and reassurance. SS offered him time to reminisce about when he was younger and mutual friends he has with SS. At the end of conversation he expressed he was doing better. he was no longer tearful and was smiling and laughing at times. SS will update psyche services and have them visit with him on next visit to the facility A Progress Note, dated 6/7/2023 at 2:22 P.M., indicated the resident was sent to the hospital to be evaluated for right lower quadrant pain. A Psychiatry Progress Note, dated 6/8/2023 from 7:30 A.M. to 7:55 A.M., indicated Symptom Description and Subjective Report; Patient is seen today for follow up assessment of mood and behavior and medications. Patient has been more irritable and made a gesture to harm himself .Objective Content: Alert and pleasant. Appears in no distress or discomfort. Resting in his bed. Engages in conversation easily. Able to make some needs known. Staff also will anticipate his needs. He had been more irritable and staff states he put the call light cord around his neck. Patient readily admits to doing so but states he was frustrated. He denies current suicidal ideations or intent to harm himself. Patient state he was in pain and didn't feel well. He was recently seen in ER [Emergency Room] and diagnoses with a UTI [Urinary Tract Infection]. He is receiving[sic] an antibiotic. Staff also report he didn't have his scheduled pain medication due to an insurance issue. Plan: Patient diagnosed with UTI and was not receiving his usual pain medication which likely contributed to his mood issues A Licensed Clinical Psychologist Progress Note, dated 6/8/2023 from 11:22 A.M. to 11:47 A.M., indicated Patient was seen in follow-up for symptoms of depression and anxiety. Staff report that patient has been wrapping his call light around in neck in a gesture to hurt himself. Patient has a UTI, and has had increased pain because insurance issues have limited the pain medications that can be used. Staff are working to resolve this issue. Patient presents as very angry, tearful and expressed a desire to end his life. He calmed down and became more rational as we talked, and more calm at the end of the session. Staff were consulted about patient's labile mood, and about ways to manage his impulsive behavior .Objective Content: Patient and I talked about the fact that he was sent to the ER a couple of days ago because of pain and a UTI and they were not helpful. At first, patient was unable to think rationally about the fact that staff are working to manage his pain, and having a UTI will contribute to him feeling bad in general. He was able to calm down, and acknowledge he is more depressed but not planning to kill himself. Upon consultation, staff indicated they plan to lower patient's bed to the floor so he cannot injure himself by throwing himself out of bed, and securing his call light and bed control so he cannot hurt himself with the cords, in case he becomes upset again and tries to get impulsively A Progress Note, dated 6/8/2023 at 1:20 P.M., indicated Resident 5 arrived back to the facility with antibiotics for the treatment of a urinary tract infection. A Care Plan, dated 6/15/2023, indicated .I display irrational thoughts and ideas related to dx [diagnosis] of psychosis r/t [related to] [NAME] [sic] Ataxia as evidenced by digging in my ears thinking my hearing aides are wedged in my ears, thinking someone is remotely messing with my computer and convinced I can have an apartment and take care of self. Leading to potential for self-harm. Resulting in use of antipsychotic medication. Interventions: Allow [Resident 5] to express his thoughts and feelings and assist in helping him understand the reality of situations. Maintain a calm, consistent environment and attend to his basic needs. Provide support with skills to de-escalate, cope and manage stress. Make sure environment is clear of clutter or self-harm objects. A Care Plan, created 1/10/2016, revised on 1/18/2023 and 6/15/2023, indicated . I have altered mood related to dx of anxiety as evidenced by yelling/screaming/cursing at staff, clenching my fist, repetitive yelling out for specific people and refuses to talk when it is not what I want to hear and I attempt to wrap call cord around my neck for staff attention. Resulting in use of anxiolytic medication. Interventions: Approach in call manner and provide comfort /assurance during times of illness. Encourage use of two staff to reposition when in bed to reduce random movements by [Resident 5], Zip tie call cord to half side rail on bed with enough length at end for him to have call cord to half rail on bed with enough lengths at end for him to have call cord in lap to prevent him from attempting to wrap call cord around his neck. Medication as ordered. Notify physician as needed. Monitor quarterly for Medication GDR for psychoactive medication. Allow time to express feelings and provide validation and comfort as needed. SS to visit PRN. Document mood and behavior #1: I have altered mood related to dx of anxiety as evidence by yelling/screaming/cursing/ at staff, clenching my fist, repetitive yelling out for specific people and refused to talk when it is not what I want to hear and I attempt to wrap call cord around my neck for staff attention. Interventions: 1. Allow [Resident 5] time to express his feelings and provide validation and comfort, if unable to understand then get another staff member to assist. 2. Offer a sip of a drink to clear throat and make sure all basic needs are met, encourage use of two when repositioning to reduce random movements by [Resident 5]. 3. Make sure [Resident name] is aware that you are here to help him and he can trust you, maintain a calm consistent responses, change caregivers if needed. 4. Make sure [Resident 5] is safe and inform him that you will return when he has time to calm down and he is ready to have a conversation. During an interview, on 7/26/2023 at 3:07 P.M., CNA 2 indicated she was working on 6/6/2023 but was not assigned to Resident 5's room. She indicated in the past she had observed the resident wrap a cord around his neck. She indicated she had rehired 10 months ago, and he had only done this a few times in the past 10 months but a few years ago when she worked here, he often displayed that behavior. She indicated he would use the call light and/ or bed remote cord. During an interview, on 7/26/2023 at 3:10 P.M., CNA 3 indicated via a phone interview she heard [Resident 5] yell and saw the bed remote cord was around his neck he would not let go, he said, Let me die I don't want to do this anymore! He was hysterically crying. He was pulling the remote cord and there were purple indents on his neck. He was lying flat on his back in bed and the cord was wrapped around the neck at least 2 times maybe 3 but definitely 2. That is the first time she had ever seen this happen. The nurse went in there to see if he was ok. She went to tell the Administrator who directed her to Director of Nursing and then told her to get the Social Worker. Afterwards if he put on the call light, we answered timely. He was not put on 1 on 1's or sent out. At 7/26/2023 at 3:28 P.M. the CNA called back she forgot to mention she was in the room during the Social Workers interview, and she stated multiple times to the resident, Don't make me send you out I don't want to have to do that! During an interview, on 7/26/2023 at 3:35 P.M., the Social Service Director indicated she believed the agency nurse contacted her about the cord around his neck. She went down to talk to him; he was very emotional and talked about why he was upset. She discussed ramifications when he puts a call light around his neck, let him express himself and reminisced which got him laughing, talking, and smiling. She did not call the doctor or psych (psychiatry) following the occurrence, but was going to schedule him on their next facility visit. She indicated the policy was to remove any harmful items, place on 1 on 1- or 15 minute checks and notify the doctor and psych. She did not remove the cord form the room, maintenance was to resecure it after she was done talking to the resident. During an interview, on 7/26/2023 at 3:49 P.M., the Director of Nursing (DON) indicated the Social Service (SS) informed her or the agency nurse. They said the resident wrapped the call light cord around his neck, so SS went down to talk to him. The DON had talked to him earlier to discuss his medications and what they were for. He was okay then. There was no problem with any of his medications. She went down and saw him after the event and he was in bed with his head of bed up watching TV. She did not see any discoloration around his neck. The call light cord was secured with zip tie so he could reach it but not pull it up. This was not the first time he did this. She was not sure how the zip tie got undone. The Maintenance Director refastened it. She did not have an investigation on this incident, and an unplanned occurrence was not filled out, but she would need to check the chart. He was okay after SS talked to him. The policy was to remove all objects that could cause harm and notify the physician and family. It should have been in the Progress Notes. During an interview, on 7/26/2023 at 3:53 P.M., the Maintenance Director indicated he had reattached the call cord to the assist/bed rails a couple times. He thought he did go last month after morning meeting at the request of the team, but did not recall any specific staff member asking him. The resident was calm and asked him to leave enough cord to go from the wall over his shoulder. I told him I couldn't do that, but then he asked if I could attach it to both the bed rail and the assist rail so it couldn't be moved. I asked him, Don't you want it to be able to reach your lap? and he said, No and indicated he would rather have it attached to the assist rail. He did not know how the zip tie got untied. He also did not indicate it was an emergency but usually when asked, he promptly responded to any request to check things out. He received a text from the DON on 6/6/2023 at 10:51 A.M., asking him to rezip the call cord in Resident 5's room. The text indicated he wrapped the cord around his neck. On 7/26/2023 at 4:10 P.M., the DON indicated that there was no unplanned occurrence or any documentation in the Progress Notes that the physician or family was notified. During an interview, on 7/26/2023 at 4:21 P.M., the Administrator indicated he could not recall who contacted him. He acknowledged the SS went to the resident's room and the resident indicated that he had no attempt to self-harm. They tell you whether that is their intentions. He had a BIMS [Brief Interview for Mental Status] of 15 (cognitively intact) so he had no plan. He indicated management does investigations and he had sent the SS. On 7/26/2023 at 4:09 P.M., the Director of Nursing provided a policy titled, Suicide Precautions, dated 6/12/2020, and indicated the policy was the one currently used by the facility. The policy indicated .2. Procedure A. When residents verbalize the intent or demonstrate an attempt at suicide, the following procedures are recommended. I. ACTUAL: a. If the resident demonstrates an actual suicide attempt, emergency admit to acute care or inpatient psychiatric care will be requested. b. A designated staff person will be assigned to observe the resident at the bedside until relocation/transfer can be completed The immediate jeopardy that began on June 6, 2023 was removed on July 27, 2023 when the facility secured all environmental hazards within Resident 5's room and ensured all staff were inserviced regarding responding to suicide attempts and removing all potential environmental hazards. The non-compliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility will need to inservice any new or agency staff ongoing. The facility will continue to monitor Resident 5 as well as all residents who are at risk for self harm. 3.1-45(a)