HospitalInspections.org

WV00025782

Based on observation, document review and staff interviews it was determined the facility failed to protect patient's rights to personal privacy and failed to inform patients they were being admitted or transferred to seclusion rooms which video recorded anyone in the room twenty-four (24) hours a day. This failure was identified in thirty-five (35) out of fifty-eight (58) patients (patients #2, 5, 17, 23, 24 and 29 through 58) admitted or transferred to be housed in the facility's video recorded seclusion rooms from 06/26/21 through 07/26/21. These findings have the potential for all patient's rights to personal privacy to be violated. (See tags A 117 and A 143).

WV00025808

Based on clinical record review, document review and staff interviews it was determined the facility failed to protect patient's rights to provide care in a safe setting. This failure was identified in one (1) out of thirty (30) patient records. These findings have the potential for all patients to be at risk for serious injury, harm or death. (See tag A 144).

A. Noncompliance: An Immediate Jeopardy (IJ) for Care in a Safe Setting and Nursing Services not Following Policy and Procedures was called on 07/28/21 at 4:17 p.m. because the facility failed to ensure the Registered Nurse conducted an Immediate Suicide Risk Assessment of a patient found on the floor with cloths wrapped around her neck and a note stating, "RIP" (rest in peace) with "patient's name" written on the note and who was yelling they didn't want to be part of this world and would kill themselves the first chance they get.

B. Harm or Potential Harm: This places all patients at risk for serious injury, harm or death.

C. Immediacy: The facility needs to take action to ensure all patients receive an Immediate Suicide Risk Assessment to reflect an accurate assessment of the patient at the time the patient attempts, gestures or verbalizes suicide.

D. A remedial plan of correction was received and sent to the State agency Program Director. The plan was accepted and the facility abated the IJ on 07/28/21 at 8:30 p.m. by immediately issuing a nursing alert to Nurse Managers, Lead Nurses, Nursing Clinical Coordinators (NCCs) and all unit Registered Nurses (RNs) on a procedure revision for facility policy "Suicide Risk" by placing all patients exhibiting suicide risk behaviors on Constant Close Observation (CCO) as soon as clinically indicated and to notify the medical staff to provide a "Medical Provider Suicide Risk Assessment." One hundred (100) percent of RNs working the facility were educated immediately and all NCCs and unit RN's would be educated at each incoming shift or the start of their next shift worked. The "Suicide Risk" policy will be reviewed and revised to determine what assessment scale will be used in place of the "Columbia Suicide Scale," and nursing documentation will be monitored for three (3) months and reported to Quality Council.

Based on observation, interviews and document review it was revealed the facility failed to ensure staff notify patients of their rights for personal privacy when they were being housed upon admission or when transferred to seclusion rooms which video recorded anyone in the room twenty-four (24) hours a day prior to receiving care. This failure was identified in thirty-five (35) out of fifty-eight (58) patients (patients #2, 5, 17, 23, 24 and 29 through 58) admitted or transferred to be housed in the facility's video recorded seclusion rooms from 06/26/21 through 07/26/21. These findings have the potential for all patient's rights to personal privacy to be violated.

Findings include:

1. An observation conducted on 07/27/21 at approximately 9:30 a.m. of Nursing Unit N2 in the presence of the Barcode Medication Administration System (BCMA) Coordinator and the Health Information Management (HIM) Director revealed two (2) seclusion rooms were located next to each other and a separate bathroom was located across the hall from the seclusion rooms. The first seclusion room door was open, the lights were off, and a patient was sleeping in the bed. The second seclusion room door was open and patient #30 was sitting in the room drinking from a cup. A camera was observed in the corner of the room on the ceiling from the doorway. When asked about the camera's recording in the seclusion room, the BCMA Coordinator and HIM Director stated in part, "We were covering them up with paper. It was the Safety Director (name) who told us not to cover the cameras up."

2. A telephone interview was conducted with Charge Aide #1 on 07/26/21 at approximately 8:20 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, Charge Aide #1 stated in part, "I assume when patients are taken into the seclusion room they would be turned off. ... I don't know if patients are being told there is a camera monitoring them. ... If patients are in there and the cameras are running, their rights to privacy are violated."

3. A telephone interview was conducted with Registered Nurse (RN) #1 on 07/26/21 at approximately 8:38 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, RN #1 stated in part, "I don't remember the specifics, but we do frequently admit to the seclusion rooms. We used to cover the camera with a Styrofoam cup. We were told to stop covering the cameras. ... I don't know if patients are told about the cameras. I have never had a discussion about the cameras with the patients in the room. ... I feel the camera is on twenty-four (24) hours seven (7) days a week in the seclusion rooms."

4. A telephone interview was conducted with Health Service Worker (HSW) #2 on 07/26/21 at approximately 8:58 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, HSW #2 stated in part, "The camera is on. There is not any discussion to tell the patient the camera is monitoring them. ... The camera is obvious, but I never had a patient question it. ... I do feel their privacy is violated. If it was my relative, it sure would be." When asked how long patients are admitted to the room, HSW #2 stated in part, "Patients are moved depending on patient transfers or discharges. Some stay a week or a day or two (2)."

5. A telephone interview was conducted with RN #2 on 07/26/21 at approximately 9:15 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, RN #2 stated in part, "Each room has a camera. Before, we would take coffee cups to put over the camera. I don't know if the camera can be turned off. We can't put cups over the cameras now. We were just told not to put cups over the cameras but had no explanation. Until recently, there was no reason to explain anything, we just covered it up. We forget it's there now. ... I wouldn't want it in my bedroom. I've never considered it and never explained it before but will now."

6. An interview was conducted with patient #30 on 07/27/21 at approximately 9:30 a.m. When asked if they were told a video camera was recording them at all times when admitted to the seclusion room, he/she stated in part, "I didn't know there was a camera until yesterday when I seen it."

7. An interview was conducted with HSW #3 on 07/27/21 at approximately 10:45 a.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, HSW #3 stated in part, "I don't tell them about the camera in the seclusion room. At one (1) point I did see the cameras covered, but it was only one (1) time. I did hear an advocate say they couldn't be covered. I think they operated twenty-four (24) hours a day, seven (7) days a week ... I do feel it is a violation of patient rights being monitored."

8. An interview was conducted with Physician #1 on 07/27/21 at approximately 11:15 a.m. When asked if patients being admitted to seclusion rooms had their privacy rights violated, the physician stated in part, "We had to use seclusion rooms if there are no other beds. ... The directive is cameras would stay on ... The expectation is staff will inform patients they are being recorded in those rooms."

9. An interview was conducted with the Chief Nursing Officer (CNO) on 07/27/21 at approximately 2:35 p.m. When asked how patient rights to privacy are being protected when admitted into video recorded seclusion rooms, the CNO stated in part, "I expect staff will inform patients going into the seclusion rooms that there is monitoring twenty-four (24) hours, seven (7) days a week." When notified patients in video recorded rooms are not receiving the same rights as patients in non-video recorded rooms, she concurred.

10. An interview was conducted with the CNO on 07/27/21 at approximately 3:30 p.m., When asked if the date was known when the directive was received for staff to stop covering the video cameras in the seclusion rooms, the CNO verbalized it was approximately 06/26/21 the directive was received but was unable to locate the emailed directive.

11. A facility computer generated list of patients admitted or transferred to seclusion rooms from 01/01/21 through 07/26/21 was received on 07/28/21. A review of the list revealed thirty-five (35) patients were admitted or transferred to facility seclusion rooms from 06/26/21 through 07/26/21.

12. A review of facility policy, "Video Monitoring," effective 02/15/19, states in part: "The video monitoring system is installed and in use in certain areas in hospital facilities to help monitor observation/seclusion rooms, day rooms, corridors, admissions, recreation, security, maintenance, and other locations not readily observed from nursing stations. Cameras are not placed in individual patient rooms (other than observations rooms) or in bathrooms or shower areas. ... The video monitoring system includes a recording feature that stores images in a digital format for a limited period of time. This provides the opportunity to review images after an incident occurs, if/when a complaint is made, and/or for other clinical and administrative purposes."

13. A review of facility policy, "Patient's Rights and Responsibilities," effective 05/15/18, states in part: "All patients must be informed of their rights as hospital patients. ... The patient or his representative has the right to make informed decisions regarding his or her care. ... The patient or the patient's representative should receive adequate information, provided in a manner that the patient or patient's representative can understand, to assure that patient or patient's representative can effectively exercise the right to make informed decisions. ... While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: to considerate and respectful care; to privacy in treatment and consultation ... the right to privacy and dignity ... to know the purpose and give consent for any recording, film, video tape, or photograph made during your treatment and the plan for disposition of those materials."

Based on observation, document review and staff interview it was determined the facility failed to protect patients' rights to personal privacy when patients were being admitted or transferred to seclusion rooms which video recorded anyone in the room twenty-four (24) hours a day. This failure was identified in thirty-five (35) out of fifty-eight (58) patients (patients #2, 5, 17, 23, 24 and 29 through 58) admitted or transferred to be housed in the facility's video recorded seclusion rooms from 06/26/21 through 07/26/21. These findings have the potential for all patients' rights to personal privacy to be violated.

Findings include:

1. An observation conducted on 07/27/21 at approximately 9:30 a.m. of Nursing Unit N2 in the presence of the Barcode Medication Administration System (BCMA) Coordinator and the Health Information Management (HIM) Director revealed two (2) seclusion rooms were located next to each other and a separate bathroom was located across the hall from the seclusion rooms. The first seclusion room door was open, the lights were off, and a patient was sleeping in the bed. The second seclusion room door was open and patient #30 was sitting in the room drinking from a cup. A camera was observed in the corner of the room on the ceiling from the doorway. When asked about the camera's recording in the seclusion room, the BCMA Coordinator and HIM Director stated in part, "We were covering them up with paper. It was the Safety Director (name) who told us not to cover the cameras up."

2. A telephone interview was conducted with Charge Aide #1 on 07/26/21 at approximately 8:20 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, Charge Aide #1 stated in part, "I assume when patients are taken into the seclusion room they would be turned off. ... I don't know if patients are being told there is a camera monitoring them. ... If patients are in there and the cameras are running, their rights to privacy are violated."

3. A telephone interview was conducted with Registered Nurse (RN) #1 on 07/26/21 at approximately 8:38 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, RN #1 stated in part, "I don't remember the specifics, but we do frequently admit to the seclusion rooms. We used to cover the camera with a Styrofoam cup. We were told to stop covering the cameras. ... I don't know if patients are told about the cameras. I have never had a discussion about the cameras with the patients in the room. ... I feel the camera is on twenty-four (24) hours seven (7) days a week in the seclusion rooms."

4. A telephone interview was conducted with Health Service Worker (HSW) #2 on 07/26/21 at approximately 8:58 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, HSW #2 stated in part, "The camera is on. There is not any discussion to tell the patient the camera is monitoring them. ... The camera is obvious, but I never had a patient question it. ... I do feel their privacy is violated. If it was my relative, it sure would be." When asked how long patients are admitted to the room, HSW #2 stated in part, "Patients are moved depending on patient transfers or discharges. Some stay a week or a day or two (2)."

5. A telephone interview was conducted with RN #2 on 07/26/21 at approximately 9:15 p.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, RN #2 stated in part, "Each room has a camera. Before, we would take coffee cups to put over the camera. I don't know if the camera can be turned off. We can't put cups over the cameras now. We were just told not to put cups over the cameras but had no explanation. Until recently, there was no reason to explain anything, we just covered it up. We forget it's there now. ... I wouldn't want it in my bedroom. I've never considered it and never explained it before but will now."

6. An interview was conducted with patient #30 on 07/27/21 at approximately 9:30 a.m. When asked if they were told a video camera was recording them at all times when admitted to the seclusion room, he/she stated in part, "I didn't know there was a camera until yesterday when I seen it."

7. An interview was conducted with HSW #3 on 07/27/21 at approximately 10:45 a.m. When asked if patients being admitted to seclusion rooms are informed, they are video recorded, HSW #3 stated in part, "I don't tell them about the camera in the seclusion room. At one (1) point I did see the cameras covered, but it was only one (1) time. I did hear an advocate say they couldn't be covered. I think they operated twenty-four (24) hours a day, seven (7) days a week ... I do feel it is a violation of patient rights being monitored."

8. An interview was conducted with Physician #1 on 07/27/21 at approximately 11:15 a.m. When asked if patients being admitted to seclusion rooms had their privacy rights violated, the physician stated in part, "We had to use seclusion rooms if there are no other beds. ... The directive is cameras would stay on ... The expectation is staff will inform patients they are being recorded in those rooms."

9. An interview was conducted with the Chief Nursing Officer (CNO) on 07/27/21 at approximately 2:35 p.m. When asked how patient rights to privacy are being protected when admitted into video recorded seclusion rooms, the CNO stated in part, "I expect staff will inform patients going into the seclusion rooms that there is monitoring twenty-four (24) hours, seven (7) days a week." When notified patients in video recorded rooms are not receiving the same rights as patients in non-video recorded rooms, she concurred.

10. An interview was conducted with the CNO on 07/27/21 at approximately 3:30 p.m., When asked if the date was known when the directive was received for staff to stop covering the video cameras in the seclusion rooms, the CNO verbalized it was approximately 06/26/21 the directive was received but was unable to locate the emailed directive.

11. A review of a facility computer generated list of patients admitted or transferred to seclusion rooms from 01/01/21 through 07/26/21 was received on 07/28/21. A review of the list revealed thirty-five (35) patients were admitted or transferred to facility seclusion rooms from 06/26/21 through 07/26/21.

12. A review of facility policy, "Video Monitoring," effective 02/15/19, states in part: "The video monitoring system is installed and in use in certain areas in hospital facilities to help monitor observation/seclusion rooms, day rooms, corridors, admissions, recreation, security, maintenance, and other locations not readily observed from nursing stations. Cameras are not placed in individual patient rooms (other than observations rooms) or in bathrooms or shower areas. ... The video monitoring system includes a recording feature that stores images in a digital format for a limited period of time. This provides the opportunity to review images after an incident occurs, if/when a complaint is made, and/or for other clinical and administrative purposes."

13. A review of facility policy, "Patient's Rights and Responsibilities," effective 05/15/18, states in part: "All patients must be informed of their rights as hospital patients. ... The patient or his representative has the right to make informed decisions regarding his or her care. ... The patient or the patient's representative should receive adequate information, provided in a manner that the patient or patient's representative can understand, to assure that patient or patient's representative can effectively exercise the right to make informed decisions. ... While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: to considerate and respectful care; to privacy in treatment and consultation ... the right to privacy and dignity ... to know the purpose and give consent for any recording, film, video tape, or photograph made during your treatment and the plan for disposition of those materials."

Based on clinical record review, document review and interview it was revealed the facility failed to ensure patient #28 received care in a safe setting by ensuring the Registered Nurse (RN) conducted an immediate suicide risk assessment when the patient was found with cloths wrapped around their neck, a suicide note on the bed and verbalizing they wanted to kill themselves. This failure was found in one (1) out of thirty (30) clinical record reviews. This failure places all patients at risk for serious injury, harm, or death.

Findings include:

1. A clinical record review conducted on 07/27/21 revealed a "Nursing Shift Assessment" dated 7/23/21 at 6:16 p.m. documented by RN (RN) #5 that states in part, "Patient found in room at 1700 (5:00 p.m.) with ripped up wash cloths wrapped around her neck as if preparing to hang herself. Note on bed saying "RIP (rest in peace) (name)" present. Wash clothes removed, provider notified at 1735 (5:35 p.m.), ... Patient continued to yell that she didn't want to be part of this world and that she'd kill herself "first chance I get."

2. A clinical record review conducted on 07/27/21 revealed a "SHA (Sharpe Hospital Admission) Nursing Admission/Re-Evaluation Columbia Suicide Scale" assessment dated 7/23/21 at 6:25 p.m. documented by RN #5 that states in part, "1) Wish to be Dead: "Yes" ... 2) Suicidal Thoughts: "Yes" ... 3) Suicidal Thoughts with Method: "No" (without specific Plan or Intent to Act) ...: 4) Suicidal Intent (without specific plan): "No" ... 5) Suicide Intent with specific Plan: "No" Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out. ... 6) Suicide Behavior Question: "Yes" ...If Yes, ask: How long ago did you do any of these? Within the last three months? Moderate/High Risk: If patient answers "yes" to questions 3, 4 or 5 emergency action is needed. Please follow the steps below: 1. Notify the on-call physician. 2. Place on CCO (continuous close observation) Suicide precautions.

3. A review of the "Columbia-Suicide Severity Rating Scale (C-SSRS), version 01/2014, states in part: "The C-SSRS Risk Assessment is intended to help establish a person's immediate risk of suicide and is used in acute care settings. ... it is intended to be followed exactly according to the instructions and cannot be altered. ... Suicidal Behavior Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be one hundred (100) percent. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt."

4. A review of facility policy, "Suicide Risk," effective 01/08/21, states in part: "Screening by nursing: RN will complete the Columbia Suicide Severity Rating Scale (C-SSRS) upon admissions, monthly and anytime a patient verbalizes suicidal thoughts or ideations, exhibits suicidal thoughts or ideations after admission to a patient care unit (Critical Junction).

5. A review of facility policy, "Nursing Documentation," effective 05/04/21, states in part: "Proper documentation is an important means of communicating information to the treatment team, for quality patient care ... General Guidelines for Documentation: 1. All entries must be dated, timed and signed. ... Suicide Scale: The Registered Nurse will complete the SHA Nursing Admission/Re-evaluation Columbia Suicide Scale in the EMR (electronic medical record), upon the patient's admission and as needed, during the patient's stay. ... Nursing shift notes: Nursing shift note reflect the patient's status at the time of the note, including any changes in the patient's condition."

6. An interview was conducted with the Chief Executive Officer (CEO) on 07/29/21 at approximately 10:45 a.m. When asked if the nurse should have documented an immediate suicide risk assessment, the CEO stated in part, "I understand your perspective and as evidenced by the immediate action plan, we are addressing it."

Based on clinical record review, document review and staff interviews it was determined the facility failed to ensure the Registered Nurse (RN) evaluates and conducts an immediate suicide risk assessment to provide safe patient care following facility policy and procedures. This failure was identified in one (1) out of thirty (30) patient records. These findings have the potential for all patients to be at risk for serious injury, harm or death. (See tag A 395 and A 398).

A. Noncompliance: An Immediate Jeopardy (IJ) for Care in a Safe Setting and Nursing Services not Following Policy and Procedures was called on 07/28/21 at 4:17 p.m. because the facility failed to ensure the Registered Nurse conducted an Immediate Suicide Risk Assessment of a patient found on the floor with cloths wrapped around her neck and a note stating, "RIP" (rest in peace) with "patient's name" written on the note and who was yelling they didn't want to be part of this world and would kill themselves the first chance they get.

B. Harm or Potential Harm: This places all patients at risk for serious injury, harm or death.

C. Immediacy: The facility needs to take action to ensure all patients receive an Immediate Suicide Risk Assessment to reflect an accurate assessment of the patient at the time the patient attempts, gestures or verbalizes suicide.

D. A remedial plan of correction was received and sent to the State agency Program Director. The plan was accepted and the facility abated the IJ on 07/28/21 at 8:30 p.m. by immediately issuing a nursing alert to Nurse Managers, Lead Nurses, Nursing Clinical Coordinators (NCCs) and all unit Registered Nurses (RNs) on a procedure revision for facility policy "Suicide Risk" by placing all patients exhibiting suicide risk behaviors on Constant Close Observation (CCO) as soon as clinically indicated and to notify the medical staff to provide a "Medical Provider Suicide Risk Assessment." One hundred (100) percent of RNs working the facility were educated immediately and all NCCs and unit RN's would be educated at each incoming shift or the start of their next shift worked. The "Suicide Risk" policy will be reviewed and revised to determine what assessment scale will be used in place of the "Columbia Suicide Scale," and nursing documentation will be monitored for three (3) months and reported to Quality Council.

Based on clinical record review, document review and interviews, it was revealed the Chief Nursing Officer failed to supervise and evaluate the Registered Nurse's care to assess and conduct an immediate and accurate suicide risk assessment for patient #28 following the Columbia-Suicide Severity Rating Scale, version 01/2014 and facility policy and procedures to maintain patient safety. This failure was identified in one (1) out of thirty (30) patients. This failure has the potential for all patients to be a risk for serious injury, harm, or death.
Findings include:
1. A clinical record review, conducted on 07/27/21 revealed a "Nursing Shift Assessment," dated 7/23/21 at 6:16 p.m. documented by Registered Nurse #5, states in part, "Patient found in room at 1700 (5:00 p.m.) with ripped up wash cloths wrapped around her neck as if preparing to hang herself. Note on bed saying "RIP (name)" present. Wash clothes removed, provider notified at 1735 (5:35 p.m.), ... Patient continued to yell that she didn't want to be part of this world and that she'd kill herself "First chance I get."

2. A clinical record review, conducted on 07/27/21 revealed a "SHA Nursing Admission/Re-Evaluation Columbia Suicide Scale" assessment, dated 7/23/21 at 6:25 p.m. documented by RN #5, states in part, "1) Wish to be Dead: "Yes" ... 2) Suicidal Thoughts: "Yes" ... 3) Suicidal Thoughts with Method: "No" (without specific Plan or Intent to Act) ...: 4) Suicidal Intent (without specific plan): "No" ... 5) Suicide Intent with specific Plan: "No" Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out. ... 6) Suicide Behavior Question: "Yes" ...If Yes, ask: How long ago did you do any of these? Within the last three months? Moderate/High Risk: If patient answers "yes" to questions 3, 4 or 5 emergency action is needed. Please follow the steps below: 1. Notify the on-call physician. 2. Place on CCO and Suicide precautions.

3. A review of the "Columbia-Suicide Severity Rating Scale (C-SSRS), version 01/2014, states in part, "The C-SSRS Risk Assessment is intended to help establish a person's immediate risk of suicide and is used in acute care settings. ... it is intended to be followed exactly according to the instructions and cannot be altered. ... Suicidal Behavior Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to one hundred (100) percent. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt."

4. A review of facility policy, "Suicide Risk," effective 01/08/21, states in part, "Screening by nursing: RN will complete the Columbia Suicide Severity Rating Scale (C-SSRS) upon admissions, monthly and anytime a patient verbalizes suicidal thoughts or ideations, exhibits suicidal thoughts or ideations after admission to a patient care unit (Critical Junction).

5. A review of facility policy, "Nursing Documentation," effective 05/04/21, states in part, "Proper documentation is an important means of communicating information to the treatment team, for quality patient care ... General Guidelines for Documentation: 1. All entries must be dated, timed and signed. ... Suicide Scale: The Registered Nurse will complete the SHA (Sharpe Hospital Admission) Nursing Admission/Re-evaluation Columbia Suicide Scale in the EMR (electronic medical record), upon the patient's admission and as needed, during the patient's stay. ... Nursing shift notes: Nursing shift note reflect the patient's status at the time of the note, including any changes in the patient's condition."

6. An interview was conducted with the Chief Executive Officer on 07/29/21 at approximately 10:45 a.m. When asked if the nurse should have documented an immediate suicide risk assessment, the CEO stated in part, "I understand your perspective and as evidenced by the immediate action plan, we are addressing it."

Based on clinical record review, document review and interviews it was revealed the facility failed to ensure the Registered Nurse (RN) assesses and conducts an immediate suicide risk assessment for patient #28 following facility policy and procedures to maintain patient safety. This failure was identified in one (1) out of thirty (30) patients. This failure has the potential for all patients to be a risk for serious injury, harm, or death.

Findings include:

1. A clinical record review conducted on 07/27/21 revealed a "Nursing Shift Assessment" dated 7/23/21 at 6:16 p.m. documented by RN (RN) #5 that states in part, "Patient found in room at 1700 (5:00 p.m.) with ripped up wash cloths wrapped around her neck as if preparing to hang herself. Note on bed saying "RIP (rest in peace) (name)" present. Wash clothes removed, provider notified at 1735 (5:35 p.m.), ... Patient continued to yell that she didn't want to be part of this world and that she'd kill herself "first chance I get."

2. A clinical record review conducted on 07/27/21 revealed a "SHA (Sharpe Hospital Admission) Nursing Admission/Re-Evaluation Columbia Suicide Scale" assessment dated 7/23/21 at 6:25 p.m. documented by RN #5 that states in part, "1) Wish to be Dead: "Yes" ... 2) Suicidal Thoughts: "Yes" ... 3) Suicidal Thoughts with Method: "No" (without specific Plan or Intent to Act) ...: 4) Suicidal Intent (without specific plan): "No" ... 5) Suicide Intent with specific Plan: "No" Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out. ... 6) Suicide Behavior Question: "Yes" ...If Yes, ask: How long ago did you do any of these? Within the last three months? Moderate/High Risk: If patient answers "yes" to questions 3, 4 or 5 emergency action is needed. Please follow the steps below: 1. Notify the on-call physician. 2. Place on CCO (continuous close observation) Suicide precautions.

3. A review of the "Columbia-Suicide Severity Rating Scale (C-SSRS), version 01/2014, states in part: "The C-SSRS Risk Assessment is intended to help establish a person's immediate risk of suicide and is used in acute care settings. ... it is intended to be followed exactly according to the instructions and cannot be altered. ... Suicidal Behavior Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be one hundred (100) percent. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt."

4. A review of facility policy, "Suicide Risk," effective 01/08/21, states in part: "Screening by nursing: RN will complete the Columbia Suicide Severity Rating Scale (C-SSRS) upon admissions, monthly and anytime a patient verbalizes suicidal thoughts or ideations, exhibits suicidal thoughts or ideations after admission to a patient care unit (Critical Junction).

5. A review of facility policy, "Nursing Documentation," effective 05/04/21, states in part: "Proper documentation is an important means of communicating information to the treatment team, for quality patient care ... General Guidelines for Documentation: 1. All entries must be dated, timed and signed. ... Suicide Scale: The Registered Nurse will complete the SHA Nursing Admission/Re-evaluation Columbia Suicide Scale in the EMR (electronic medical record), upon the patient's admission and as needed, during the patient's stay. ... Nursing shift notes: Nursing shift note reflect the patient's status at the time of the note, including any changes in the patient's condition."

6. An interview was conducted with the Chief Executive Officer (CEO) on 07/29/21 at approximately 10:45 a.m. When asked if the nurse should have documented an immediate suicide risk assessment, the CEO stated in part, "I understand your perspective and as evidenced by the immediate action plan, we are addressing it."