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Based on interview, record review, and review of the facility policy, it was determined the facility failed to provide care for one of ten sampled patients (Patient #1) in a safe setting (see A0144). Patient #1 was admitted to the facility on 11/06/12, with a known history of exhibiting self-harming behaviors such as cutting himself/herself. In addition, the patient had cut himself/herself with glass three times while in the facility. The facility staff allowed Patient #1 to purchase cologne in a glass container while at the facility, but failed to supervise and ensure the patient used the cologne safely. On 11/29/12, Patient #1 was found in the patient's room with glass (identified as a broken cologne bottle) in his/her hand and with lacerations on the left upper extremity. Patient #1 was placed on one to one supervision at all times due to the patient's behavior of cutting. Patient #1 was transferred to the Emergency Room (ER) for treatment of the areas, which required 19 staples and 19 sutures. While in the ER, staff left the patient unsupervised to take a break and the patient cut himself/herself again with a scalpel. The lacerations required seven staples. The failure of the facility to provide a safe environment placed patients at risk for serious injury, harm, impairment, or death. The facility was notified on 12/05/12, that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 12/06/12, prior to exit (refer to A0144).

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure patients received care in a safe setting for one of ten sampled patients (Patient #1). Patient #1 was admitted to the facility on 11/06/12, with a known history of exhibiting self-harming behaviors such as cutting himself/herself. In addition, the patient had cut himself/herself with glass three times while in the facility. Patient #1 purchased cologne in a glass container while at the facility, but the facility failed to supervise and ensure the patient used the cologne safely. On 11/29/12, during seven and one-half minute safety checks, Patient #1 was found in the patient's room with self-inflicted lacerations to the left upper extremity and had glass (from a broken cologne bottle) in his/her hand which the patient then placed in the patient's mouth. Patient #1 was placed on one to one supervision and transferred to the Emergency Room (ER) for treatment of the self-inflicted wounds that required 19 sutures and 19 staples. While in the ER, staff left Patient #1 unsupervised to take a break and the patient cut himself/herself again with a scalpel requiring treatment of seven staples.

The findings include:

A review of the Psychiatric Center policy, entitled Patient Clothing and Personal Belongings (revised date August 2005), revealed purses and dangerous articles should not be placed in the patient's custody during hospitalization.

A review of the Medical Record for Patient #1 revealed the patient was admitted on 11/06/12, with diagnoses to include Depression, Post-Traumatic Stress Disorder (PTSD), and self-inflicted lacerations to the upper extremities. Further review of the medical record revealed Patient #1 had cut himself/herself three times while in the facility. A review of the nurse's notes dated 11/29/12, revealed Patient #1 was on seven and one-half minute safety checks until the patient exhibited self-harming behavior at which time the patient was placed on one on one monitoring. Further review of the nurse's notes revealed Patient #1 was sent to the ER for evaluation and treatment of the arm lacerations (the patient received sutures and staples) and possible ingestion of glass.

A review of the facility Report of Unusual Incidents (RUI) dated 11/29/12, revealed Patient #1 was found by a staff member in his/her room with cuts to the patient's left arm and hand. The areas required treatment of 19 sutures and 19 staples.

Interview with Nursing Assistant (NA) #1 on 12/04/12, at 12:31 PM, revealed the NA was checking on Patient #1 for the 7 1/2 minute safety check and could not open the patient's door and immediately notified the nurse. The interview further revealed the NA was able to get the door open enough for the nurse to get into the room. Patient #1 was found sitting on the bed with lacerations on the left upper arm, glass (from a cologne bottle that staff had allowed the patient to purchase in the facility) in his/her hand and glass on the table beside the bed. The interview further revealed more staff came into the room to remove the glass and to talk with the patient about giving the piece of glass in his/her hand to staff, but the patient placed the piece of glass in the patient's mouth. The NA revealed Patient #1 had informed staff in a team meeting on 11/30/12, that the patient had "snuck" behind the desk and got the cologne bottle. The interview further revealed patients' personal items were kept behind the nurses' station in a drawer, but the drawer did not lock. NA #1 revealed personal items were supposed to be given out to patients one at a time and closely monitored by staff while the patient used the item in front of the nurses' station. The interview further revealed Patient #1's room was searched often and the staff was instructed to look around the patient's room anytime the staff was in the room for monitoring.

Interview with Registered Nurse (RN) #1 on 12/04/12, at 1:51 PM, revealed on 11/29/12, NA #1 was doing seven and one-half minute safety checks and was unable to get into Patient #1's room. RN #1 stated the NA pushed the door open enough for the RN to get in the room. Patient #1 was sitting on the edge of the bed cutting himself/herself with a piece of glass, which the patient then placed in his/her mouth. RN #1 further stated there were more pieces of glass on the desk that were identified as pieces of glass from a cologne bottle that staff had allowed the patient to purchase in the facility. The interview further revealed while RN #1 was talking with the patient and trying to get the patient to spit the glass out and wrap the patient's arm in towels, other staff members were cleaning the glass off the desk. The RN stated Patient #1's level of supervision was changed at this time to one on one. RN #1 stated personal items were kept behind the nurses' station in a drawer that could be reached by patients. The RN also stated personal items were supposed to be used in front of the nurses' station so the patients could be monitored when the items were used.

Interview with RN #2 on 12/05/12, at 11:51 AM, revealed on 11/29/12, the RN went into Patient #1's room to help calm the patient down and help clean the patient and the room. The interview further revealed RN #1 was talking with the patient while RN #2 cleaned up the glass lying on the desk and noticed the glass appeared to be from a cologne bottle. RN #2 stated room checks were done on Patient #1's room often and the patient's room was cleaned by Housekeeping daily. The interview further revealed patients' personal items were kept behind the nurses' station in an unlocked drawer.

Interviews with Licensed Practical Nurses (LPNs) #1 and #2 and NAs #2 and #3 on 12/05/12, revealed Patient #1's room was searched often for unsafe items specifically after the patient had harmed himself/herself or if there was a suspicion the patient had something dangerous. The interview further revealed the staff was instructed to look for dangerous items anytime staff was in the patient's room for safety monitoring. The staff stated personal items could only be used at the nurses' station while being monitored. The staff further stated the items were kept behind the nurses' station in an unlocked drawer that could easily be reached by the patients. The interview further revealed that patients were allowed to purchase glass cologne bottles from the facility store, but the items were stored with the patient's personal items.

Interview with Nurse Manager (NM) #1 on 12/04/12, at 1:42 PM revealed after the incident on 11/29/12, of Patient #1 cutting himself/herself and being found with glass, the patient's room and bathroom were thoroughly cleaned and searched. The interview further revealed the NM and a Housekeeping staff member were checking Patient #1's bathroom and observed the toilet did not flush well. The housekeeper put her hand in the toilet and pulled out a handful of glass that was identified as a broken cologne bottle. The NM stated patient personal items at that time were kept behind the desk in an unlocked drawer.

Interview with the Executive Director (ED) of Psychiatry on 12/04/12, at 5:50 PM, revealed Patient #1's room had been searched multiple times for unsafe items during the patient's hospital stay and the patient's level of supervision had been changed multiple times due to the patient's behaviors. On 11/29/12, Patient #1 was on seven and one-half minute checks but was changed to one on one supervision after the patient cut himself/herself. The glass Patient #1 was cutting himself/herself with was identified as a cologne bottle and more pieces of the broken cologne bottle were found in the patient's toilet when a very thorough room search was completed. The interview further revealed Patient #1's room searches were very thorough and Housekeeping had been instructed to do a more thorough cleaning of the patient's room each day by moving furniture and vacuuming around the wood in the patient's room. The ED also stated Patient #1's room had been moved multiple times. The interview further revealed when it was identified the glass Patient #1 was recently using to cut himself/herself was a cologne bottle, the personal items were moved from a drawer right behind the nurses' station to the back of the nurses' station in the chart room.

Review of the Report of Unusual Incident (RUI) dated 11/29/12, revealed while Patient #1 was in the ER for treatment of self-inflicted lacerations, the patient cut himself/herself on the left arm with a scalpel requiring treatment of 7 staples. Patient #1 required one to one supervision with Psychiatric Center staff and the staff member asked the ER nurse for a 15-minute break. While the Psychiatric staff member was on break, the ER nurse had to leave Patient #1's room to attend to an emergency leaving the patient unsupervised. Patient #1 cut himself/herself with the scalpel while left unsupervised.

Interview with NA #1 on 12/04/12, at 12:31 PM, revealed the NA was assigned to supervise Patient #1 with one to one supervision while the patient received treatment for self-inflicted lacerations in the ER. The NA stated he requested a break from RN #3 and left Patient #1 to take his break. The interview revealed NA #1 was on a break for about 15-20 minutes and when the NA returned to Patient #1's room the patient was receiving treatment (7 staples) to the self-inflicted laceration to the left arm. NA #1 stated he had looked around Patient #1's room for unsafe items when they first entered the room, but did not see any unsafe items.

Interview with RN #3 on 12/04/12, at 12:40 PM, revealed Patient #1 was RN #3's patient in the ER on 11/29/12, and was in the ER for treatment of self-inflicted lacerations to the left arm. The interview further revealed NA #1 requested RN #3 to check on Patient #1 and the RN informed the NA he would check on the patient as soon as he could. RN #3 stated he/she was very busy with other patients and it was several minutes before the RN went into Patient #1's room. The interview further revealed when the RN walked into the patient's room, Patient #1 had a scalpel in his/her hand and had cut his/her arm. Patient #1's self-inflicted laceration required treatment of 7 staples. RN #3 denied being aware where Patient #1 could have obtained the scalpel and stated Patient #1 stated he/she had the scalpel when he/she came to the ER. The interview further revealed RN #3 had checked the exam room that morning for unsafe items and denied any unsafe items being found in the room.

Interview with Emergency Room Nurse Manager (NM) #2 on 12/04/12, at 3:29 PM, revealed the NM was not aware of how Patient #1 obtained the scalpel. The interview further revealed the exam rooms were checked each morning for unsafe items and the NM denied having identified any problems with staff leaving out dangerous items.

Immediate Jeopardy was determined to be abated on 12/06/12, prior to exit of the survey.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure the delivery of nursing services to one of ten sampled patients (Patient #1). Patient #1 was admitted to the facility on 11/06/12, with a known history of self-harming behaviors such as cutting himself/herself. On 11/29/12, Patient #1 was admitted to the Emergency Room (ER) from the Psychiatric Center for treatment of self-inflicted lacerations to the left arm requiring closure with 19 sutures and 19 staples. Patient #1 was assessed to require one to one supervision (face to face monitoring with staff close enough to intervene quickly at all times) due to self-harming behaviors. However, while in the Emergency Room for treatment Patient #1 was left unsupervised by Registered Nurse (RN) #3 and Nurse Assistant (NA) #1. Patient #1 cut himself/herself with a scalpel while left unsupervised, requiring treatment of 7 staples to close the self-inflicted wound. The facility was notified on 12/05/12, that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions on 12/05/12. It was determined the Jeopardy was abated on 12/06/12, prior to the survey exit (refer to A0395).

Based on interview, record review, and review of the facility policies and guidelines, it was determined the facility failed to supervise the nursing care to ensure patients at risk for self-harm were properly and adequately supervised for one of ten sampled patients (Patient #1). On 11/29/12, Patient #1 was admitted to the Emergency Room (ER) for treatment of self-inflicted lacerations. Patient #1 was assessed to require a supervision level of one to one monitoring (face to face monitoring with staff close enough to intervene quickly at all times); however, the facility failed to provide the required level of supervision and Patient #1 cut himself/herself with a scalpel that required treatment of 7 staples to close the wound.

The findings include:

A review of the facility's policy entitled One to One Intervention (revision date 10/08) revealed to provide for patient safety the facility would provide adequate staff to monitor patients who demonstrate a need for close observation. The policy stated one to one monitoring was accomplished by face to face monitoring with staff close enough to intervene quickly at all times. According to the policy, when assigned one to one monitoring, this was the staff person's only duty. The assigned staff member was to remain with the patient until relieved by another designated staff member.

A review of the guidelines for One to One Monitoring revealed monitoring meant one to one patient visualization at all times. The staff was required to sit at the patient's bedside and have the patient remain within arm's length. Staff was also required to make environmental sweeps of the patient's room.

A review of the facility's policy entitled Sitter Policy/Procedure revealed sitters were designed to assist in creating a safe environment for patients, using the least restrictive interventions feasible and allow direct observation of those patients with behavior health diagnoses and/or those patients deemed to be a danger to self or others. Sitters were required to provide direct observation to meet the immediate safety needs of those patients.

A review of the Personal Care Assistant (Sitter) Task List (revision date 12/12) revealed the sitter would remain with his/her patient until he/she was relieved for a break. When a PCA required a break, he/she would notify the patient's assigned nurse, Clinical Nurse Manager, or Nurse Manager. If staff was unable to reach these staff members, staff was required to contact the House Supervisor.

A review of the Report of Unusual Incidents (RUI), dated 12/29/12, revealed while Patient #1 was in the ER for treatment of an earlier self-inflicted wound, the patient cut himself/herself on the left arm with a scalpel requiring treatment of 7 staples. The RUI further revealed Patient #1 required one to one supervision by a Psychiatric staff member. The Psychiatric staff member asked the ER nurse to watch the patient while the staff member took a 15-minute break. The ER nurse left to attend to an emergency in the ER, and at that time Patient #1 cut himself/herself with a scalpel.

Interview with NA #1 on 12/04/12, at 12:31 PM, revealed the NA was assigned to monitor Patient #1 with one to one supervision while the patient received treatment of self-inflicted lacerations in the ER. The interview further revealed the NA stood in the doorway and requested a break from RN #3. The RN agreed to give the NA a break if NA #1 would take another patient out to smoke while on the break. NA #1 stated RN #3 was standing in the doorway when the NA left Patient #1's room for a break and the NA escorted the other patient out to smoke. The interview further revealed NA #1 was on break for about 15 to 20 minutes and when he/she returned to Patient #1's room, the patient was receiving treatment (7 staples) to the self-inflicted laceration to the left arm. NA #1 stated he/she had looked around the room for unsafe items when they first entered the room, but did not see any unsafe items. NA #1 denied being trained regarding a specific person to call for a break while monitoring a patient in the ER and was under the impression staff could request a break from the ER staff or call back to the Psychiatric Unit for a break. NA #1 stated a patient should always be within arm's distance when being monitored one to one and he/she would never leave a patient that was not being monitored appropriately.

Interview with RN #3 on 12/04/12, at 12:40 PM, revealed Patient #1 was assigned to RN #3 while in the ER on 11/29/12. RN #3 stated the patient was in the ER for treatment of self-inflicted lacerations to the left arm. The interview further revealed NA #1 was monitoring Patient #1 and came into the hallway and requested RN #3 to check on Patient #1. RN #3 stated the RN informed NA #1 he would get to the room to check on the patient as soon as he could. RN #3 denied being aware Patient #1 was supposed to have one to one supervision because the RN had not had time to look at the patient's paperwork. The RN further denied being aware NA #1 was asking for a break. The interview further revealed RN #3 was very busy with other patients and it was several minutes before the RN went into Patient #1's room to check on the patient. RN #3 stated when the RN walked into the patient's room, Patient #1 had a scalpel in his/her hand and had cut his/her left arm. The RN asked the patient for the scalpel and the patient handed the RN the scalpel. Further interview revealed Patient #1's laceration required 7 staples to close the wound. RN #3 denied being aware of where Patient #1 could have obtained the scalpel and stated Patient #1 stated he/she had come to the ER with the scalpel. The interview further revealed the exam room had been checked that morning for dangerous items and no dangerous items and RN #3 denied any dangerous items being found in the room. RN #3 further revealed the Psychiatric staff was required to call the Psychiatric Unit for breaks, not ER staff. The interview further revealed RN #3 was trained on one to one supervision in November 2012 and was aware a patient on one to one supervision should never be left unsupervised.

Interview with RN #4 on 12/04/12, at 3:25 PM, revealed Psychiatric Center patients were monitored by Psychiatric staff while in the ER for treatment. The interview further revealed the Psychiatric staff should call the House Supervisor when the staff needed a break and the ER Nurse should only provide the breaks if the nurse did not have many ER patients. RN #4 stated ER staff was trained on how to provide one to one supervision and a patient on one to one supervision should never be left unsupervised.

Interviews with NA #2 and Licensed Practical Nurses (LPNs) #1 and #3 on 12/04/12 and 12/05/12, revealed the staff was not aware of a specific policy that detailed who staff should call for a break if sitting one to one with a patient in the ER. The interview further revealed the staff would ask the ER Nurse.

Interview with ER Nurse Manager (NM) #2 on 12/04/12, at 3:29 PM, revealed patients admitted to the ER from the Psychiatric Center should have a sitter with them from the Psychiatric Center and if the staff needed a break, they should call the House Supervisor. The interview further revealed the ER exam rooms were checked each morning for unsafe items and ER Nurse Manager #2 denied having identified any problems with staff leaving out dangerous items.

Interview with Education RN #6 on 12/04/12, at 3:40 PM, revealed the education provided for one to one supervision did not include who staff needed to call for a break.

Interview with Risk Manager #1 on 12/04/12, at 5:40 PM, and on 12/06/12, at 2:15 PM, revealed the investigation of the incident was not completed, but the facility had identified a problem with the supervision provided during the incident.

Interview with the Administrator on 12/04/12, at 5:50 PM, revealed the facility had identified a problem with the supervision during this incident.