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Based on observation, interview, and record review, the provider failed to ensure:
*Environmental safety concerns for psychiatric patients had been completely addressed after identification on the hospital's Pro-Active Safety Assessment-Suicide Prevention form for all patients for one of one psychiatric hospital unit.
*Risk factors related to self-harm or attempted suicide had not been completely addressed after three sampled patients (1, 2, and 3) had attempted suicide.
*All patients on the psychiatric unit received care in a safe setting.
Findings include:

1. Observation tour on 11/23/15 at 3:00 p.m. of the hospital's ten bed psychiatric unit revealed several environmental hazards for patients that might attempt suicide by hanging or self-harm. The observation tour revealed:
*The public toilet used by patients and visitors had exposed plumbing and the handwashing sink had a long single handle to turn the water on and off.
*The activity room had a media cart with a long extension cord wrapped around the handle used to push the cart.
*All beds on the unit had four siderails that could be lowered and raised. The two upper siderails had bed controls that lowered and raised the bed.
*Review of three patient rooms revealed long exposed toilet plumbing, long blade handles to turn the water on and off, a long neck faucet, and long water control handles in the showers.

Interview with the unit manager at the time of the above observations revealed:
*That was the set-up in all patient rooms. She confirmed there was a potential suicide risk by hanging from the shower, faucet, and toilet plumbing fixtures.
*A Pro-Active Safety Assessment - Suicide Prevention form had been completed on the unit in November 2014 and again in November 2015.
*Changes had been made to the unit's environment:
-Extra cameras had been installed and some had been adjusted to get a better view of the unit.
-Elbow brackets on the doors used to keep them opened had been removed.
-The electrical cords on the beds had been shortened.
-Locks had been removed from the bathroom doors.

Review of the provider's 11/5/14 Pro-Active Safety Assessment - Suicide Prevention form revealed the "current risks":
"1. Bathroom doors - should be locked unless contraindicated by state law - we do not lock bathroom doors, however we do have exposed toilet pipes and flush handle that pose a risk along with shower knobs in the bathroom." The bathroom locks were removed on January 27, 2015.
"2. Bedroom doors should swing out into the corridor to prevent patient from barricading themselves in the room - Most patient doors swing inward - capable of blocking the door with heavy furniture."
"3. Use suicide-proof door handles or push pull latches installed upside down."
"4. Door hinges should be non-rising pin type with "hospital tip" - this was present in the 266 room with a bed, most other patient rooms had regular door hinges." The undated ProActive Risk Assessment Action Plan indicated removal of the hinges on top of door had been completed 3/1/15.
"5. Manual beds are preferred. If electrical beds are to be used, provide key lockout switches so only staff can operate beds. All electrical cords should be secured and shortened. We have all electrical beds with controls and electrical cords exposed."
"6. Have non-accessible solid ceilings. Kitchen and halls have accessible ceilings. Consider locking kitchen unless staff are present and purchasing additional cameras for hallways that do not currently have camera coverage. Staff name [____] has work order in for more cameras- we have cameras just need to be installed."
"7. Mirrors - polycarbonate or polished metal type only. No glass mirrors. Secure with tamper-resistant screws or recess them into the wall. Most patient rooms have glass mirrors." The undated ProActive Risk Assessment Action Plan indicated the maintenance staff had inspected and noted all mirrors were made of nonbreakable material.
"8. Light fixtures should be secured with tamper-resistant screws. No glass components in any fixtures. If not recessed, cover light fixtures with safety cages to minimize damage or removal. Shatter-resistant light bulbs. Most patient rooms have bulbs easily accessible including the kitchen. Patient room #266 room with bed did not have easily accessible bulbs."
"9. The heat registers in most patient rooms are a cutting risk. Some rooms the wire mold conduit would be a hanging/choking risk." The undated ProActive Risk Assessment Action Plan indicated this had been corrected on 3/15/15.
"10. Handrails in hallways are a hanging/choking risk."
"11. Door to kitchen is high risk - magnet closer, knob, hinge."
"12. TV room - mini blind with no cord- however consider the other cords within the blind."
"13. Kitchen blinds- plastic and sticks within the blind. Consider removing and tinting windows."
"14. An upgraded camera system so more areas are accessible by camera." Action was completed 2/1/15.

The provider's 11/5/14 undated Pro-Active Safety Assessment - Suicide Prevention form revealed the below listed immediate fixes had occurred:
"1. 2N06 Hall Bathroom - remove the privacy curtain. (Done)
2. Lock top cupboards in kitchen (Done)
3. Have light removed above kitchen sink
4. Remove window latches
5. Remove plastic emesis bags from rooms (Done)
6. Remove closet doors in patient rooms
7. Remove bedside waste bags. (Done)"

Review of the ProActive Risk Assessment Action Plan revealed:
1) Bathroom doors: room 266 had door that swung both ways, was budgeted for 3/31/15, and moved to fiscal year (FY) 2017 budget.
2) Patient room doors: create doors that swing both ways, budgeted for 3/31/15 remodel, and moved to FY 2017 budget.
3) Suicide proof door handle latches: remove door handles, etc with possible high risk for self harm, budgeted for remodel 3/31/15, and moved to FY 2017 budget.
4) Manual beds: replace hospital beds with box beds in some rooms, budgeted for remodel 3/31/15, and moved to FY 2017 budget.
5) Non-accessible solid ceilings: build new unit and was budgeted for year 2019.
6) Light fixtures: shatter proof light fixtures, price and budget for 3/31/15, and moved to FY 2017 budget.
7) Handrails: price and budget for 3/31/15. Moved to FY 2017 budget.
8) Doors: remove possible self harm risks. Removed hinge on top of door completed 3/1/15.
9) TV room and kitchen blinds: tint windows. Price and budget for 3/1/15 and moved to FY 2017 budget.

Review of the provider's 11/17/15 Pro-Active Safety Assessment - Suicide Prevention form revealed there were twelve environmental items listed for being a risk to patients. The list had not been updated to remove at risk items that had been corrected as noted on the 11/5/14 Pro-Active Safety Assessment - Suicide Prevention form.

Interview on 11/24/15 at 7:35 a.m. with the unit manager revealed:
*She had completed the Pro-Active Safety Assessment - Suicide Prevention form dated 11/5/14 and 11/17/15.
*The Pro-Active Safety Assessment - Suicide Prevention form dated 11/5/14 had been presented at the Risk Management Patient Safety Committee Meeting.
*Most of the items identified on the Pro-Active Safety Assessment - Suicide Prevention form were budgeted for 2017.
*The Pro-Active Safety Assessment - Suicide Prevention form dated 11/17/15 had just been completed and had not been presented to the Risk Management Patient Safety Committee yet.

Interview and review on 11/24/15 at 2:55 p.m. with the medical director of the behavioral health unit, unit manager, and the director of quality regarding the Pro-Active Safety Assessment - Suicide Prevention risk assessments dated 11/5/14 and 11/17/15 revealed:
*The environmental risk factors for patients attempting suicide by hanging had not been mitigated (fixed).
*The medical director stated the lists needed to be prioritized and 2017 was not an acceptable date to implement changes. Changes needed to occur sooner.
*Door hinges had been removed.
*Extra cameras had been installed.
*To fix patient bedroom doors and the bathroom doors to prevent suicide risks might cost at least $3,500 per door.
*The electrical cords on the electrical beds had been shortened, they were not sure if the bottom bedrails were removable, the beds were not in a lock-out mode and could be raised or lowered.
*The ceiling tiles were still removable and posed a hanging risk.
*The mirrors were made of non-breakable material.
*The hospital was looking at remodeling the behavioral unit or constructing a new unit.

2. Review of the medical records revealed two patients had attempted suicide after the Pro-Active Safety Assessment - Suicide Prevention form had been completed on 11/4/14 and one patient prior to completion of the 11/17/15 form.

a. Review of the medical record for patient 1 revealed he had been admitted on 11/16/15 with diagnoses of recurrent severe major depressive disorder with psychotic features; anxiety, and severe cannabis use disorder. On 11/18/15 he had attempted suicide by hanging. A registered nurse (RN) had found the patient with a sheet tied around his neck with the other end tied into a knot and draped over the bathroom door.

b. Review of patient 2's mental health assessment note dated 1/24/15 at 4:45 p.m. revealed she had lodged two chairs up against the bed and the door. She had tied the bed sheet around her neck twice and had it twisted hard and tight around her neck. She was pulling on the sheet with her right arm, had her back up against the foot of the bed, and was on the verge of "consciousness".

Review of patient 2's history and physical report the physician signed on 1/24/15 at 10:29 p.m. revealed the patient had turned on the shower in her bathroom and blocked the door with her bed. She had been found lying on the floor with a sheet around her neck and the other sheet around the "bedpost" [siderail].

c. Review of patient 3's medical record revealed he had been admitted on 2/11/15 and discharged on 2/12/15. His history and physical report dated 2/11/15 revealed diagnoses of severe major depressive disorder, history of alcohol use disorder, and personality disorder.

Review of patient 3's mental health assessment dated 2/12/15 revealed during a fifteen minute check a nurse aide had asked the RN to check on the patient. Upon entering the patient's room the RN saw a knotted towel hanging at the top of the bathroom door, pushed the door open with some resistance, and found the patient standing on the toilet with a towel wrapped around his neck like a noose. A rapid response and code yellow was called. The patient was alert, tearful, red faced, unwilling to follow directions, refused to allow the staff to loosen the noose, and was restrained by the staff. The patient continued to fight the staff, the police were called, and the patient was tased (to shoot with a Taser gun) by the police.

Based on observation, interview, and record review, the provider failed to ensure:
*Environmental safety concerns had not been addressed for three of three sampled psychiatric patients (1, 2, and 3) that had attempted suicide.
*All patients on the psychiatric unit received care in a safe setting.
Findings include:

1. Review of the medical record for patient 1 revealed he had been admitted on 11/16/15 and was discharged on 11/20/15.

Review of patient 1's history and physical report signed 11/16/15 at 10:24 p.m. revealed:
*His diagnoses were major depressive disorder and severe with psychotic features; anxiety disorder, and severe cannabis use disorder.
*The patient had attempted to strangle himself with a belt while in jail.
*He complained of "auditory [hearing] hallucinations telling him to kill himself."
*He stated over the last few months he had attempted to end his life several times.
*He denied homicidal thoughts, obsessions, compulsions, paranoia, and delusions.
*Mentally his senses were clear, oriented to person, place, and time; attention and concentration was fair; and his insight and judgement was poor.
*His plan included admission to Avera St. Luke's behavior health unit and place him on suicide precautions.

Review of patient 1's mental health assessment dated 11/18/15 at 2:36 p.m. revealed:
*At 2:00 p.m. the patient had requested Ativan (antianxiety medication) to help with the voices he was hearing. He was informed he could have Ativan in thirty minutes, and voiced his understanding.
*At 2:15 p.m. the patient call light rang at the nurses' station, staff looked at the camera monitor, and it appeared the patient was in the bathroom. Staff asked if he needed assistance and received no answer. A staff member reported they had just been in the patient's room to ask if he wanted to attend group, but the patient was in the bathroom.
*A registered nurse (RN) went to the patient's room, opened the door, saw a sheet with a knot draped over the closed bathroom door.
*The RN "opened the door, found the patient on the other side with the other end of the sheet tied in a knot around the patient's neck."
*"Patient was not suspended and feet were flat on the ground, but the sheet was fairly tight."
*The patient was eased to the floor, the sheet was untied and removed, and he fluttered his eyes several times before opening them.
*There was no loss of consciousness, he was orientated times three (person, place, and time), and his memory recall was immediate.
*His blood pressure was 143/77, respirations 16, pulse 90, and his oxygen saturation was 98 to 100 percent (amount of oxygen circulating in the blood).
*The patient stated "he just wanted to end it all."

2. Review of the medical record for patient 2 revealed:
*She had been admitted on 1/24/15 and was discharged on 1/25/15.
*The behavioral health team conference had identified suicidal ideation as a problem.
*The patient was on every fifteen minute close observation checks.

Review of the behavior management ability note dated 1/24/15 at 4:45 p.m. revealed:
"At 15:30 [3:30 p.m.] she asked to call her sister. At this time a note was found in front of the door of her room and the door was closed. The note stated that I'm sorry IT's too late and she signed it. She had lodged 2 chairs up against the bed and the door. She tied the bed sheet around her neck twice and had it twisted hard and tight around her neck. She was pulling on the sheet with her right arm and had her back up against the foot of the bed. She had her eyes closed and her hand was pulled off the sheet. She was on the verge of consciousness. The sheet was taken off her neck. She had a pulse and was breathing and shortly after within 30 secs [seconds] opened her eyes. She was mad and asked why the staff didn't wait one more minute and I would have been gone. I would have been at peace and my pain would have been gone. She described the darkness that she saw. She was angry and said how nobody cares about her and that staff is just doing her job. Reassurance and support provided."

Review of patient 2's history and physical report electronically signed on 1/24/15 revealed:
*Chief complaint: Suicidal thoughts.
*History of present illness:
-The patient had presented to the hospital's emergency department (ED) after having a seizure while in jail.
-She expressed thoughts of suicide while in the ED and was admitted to the mental health unit.
-Shortly after her arrival on the unit she had turned on her bathroom shower and blocked the door with her bed.
-"She was found lying on the floor with a sheet around her neck and the other sheet around bedpost. The nurses immediately untied the sheet. She lied on the floor for several minutes crying, stating that if she had 1 more minute she could have died."
-The patient had attempted suicide three or four times in the past. The last time was two weeks ago when she had taken a bottle of Dilantin (seizure medication) and half a bottle of Xanax (antianxiety medication).
*She had no history of mania, psychosis, but had stated anxiety and panic feelings.
*Past psychiatric history:
- Her last admission to Avera St. Luke's mental health unit was in 2011.
-She was currently taking Xanax and had used Wellbutrin (antidepressant) and Zoloft (antidepressant) in the past.
*Past medical history: Seizure disorder.
*Thought content: "Patient endorses suicidal thoughts with plan to overdose or hang herself."
*Assessment: Major depressive disorder, recurrent, severe.
*The plan for the patient was:
-Admission.
-Twenty-four hour hold.
-One-to-one observation because of recent suicide attempt.

Review of patient 2's discharge summary signed on 1/26/15 revealed the patient continued to have suicidal thoughts with plan to overdose or hang herself. "She was transferred to [hospital name] for further evaluation and management." The patient condition on discharge was listed as "The patient was discharged in need of further psychiatric care."

3. Review of the medical record for patient 3 revealed:
*He had been admitted on 2/11/15 and was discharged on 2/12/15. Further review of the medical record revealed:
*The behavioral health team conference dated 2/12/15 had identified suicidal ideation as a problem.
*The patient was on every fifteen minute close observation checks.
*He was on a twenty-four hour hold.

Review of patient 3's history and physical report signed 2/11/15 at 8:37 p.m. revealed:
*The patient had a history of depression and had a lot of stressors in the past few months.
*He had been admitted to Avera St. Luke's mental health unit and Human Services Center in the past.
*He denied suicidal thoughts, homicidal thoughts, hallucinations, obsessions, compulsions, and there was no evidence of paranoia or delusions.
*He was oriented, memory intact, attention and concentration was fair, and his insight and judgment was limited.
*His assessment was recurrent, severe major depressive disorder, history of alcohol use disorder, and personality disorder.
*The plan was to admit him to Avera St. Luke's mental health unit and was on suicide precautions.

Review of patient 3's mental health unit assessment documented on 2/12/15 at 10:45 a.m. revealed:
*During a fifteen minute check a nurse aide had asked the registered nurse (RN) to check on the patient.
*The RN saw a knotted towel hanging at the top of the bathroom door, pushed the door open with some resistance, and found the patient standing on the toilet with a towel wrapped around his neck as a noose.
*A rapid response and code yellow was called.
*The patient was alert, tearful, red faced, unwilling to follow directions, refused to allow the staff to loosen the noose, and was restrained by the staff.
*The patient continued to fight the staff, the police were called, and the patient was tased (to shoot with a Taser gun) by the police.
*The patient was medically cleared, was taken to jail, and the psychiatrist was notified.

4. Interview and review on 11/24/15 at 9:40 a.m. and 2:30 p.m. of patients 1, 2, and 3's medical records with the unit manager revealed:
*She had completed a Pro-Active Risk Safety Assessment - Suicide Prevention form for the unit's environment.
*Risk factors for patients to commit self-harm had been identified.
*Not all environmental items identified on that risk assessment had been implemented. Some had been tabled for the 2017 budget.
*Patients 1, 2, and 3 had attempted suicide by hanging. All had used sheets, two had tied a knot in the sheet and draped it over the bathroom door, and one had tied the sheet to the siderail on her bed.
*Not all risk factors or methods of hanging used by patients 1, 2, and 3 had been addressed. The bathroom door, plumbing in the patients' bathrooms, and bedrails were still accessible for patients to do self-harm.
*If it was determined by the patient's physician they required a higher level of care one-to-one staffing would have been assigned to the patient. Otherwise the patients were on every fifteen minute visual checks by eyes-on the patient or camera monitoring.
*There was no policy and procedure regarding the Pro-Active Risk Safety Assessment - Suicide Prevention form.
*There was no policy for environmental rounds that would be conducted on the unit periodically. However those rounds were not specific for suicide risk factors or self-harm assessment.

Based on observation, interview, and record review, the provider failed to ensure:
*Environmental safety concerns for psychiatric patients had been completely addressed after identification on the hospital's Pro-Active Safety Assessment-Suicide Prevention form for all patients for one of one psychiatric hospital unit.
*Risk factors related to self-harm or attempted suicide had not been completely addressed after three sampled patients (1, 2, and 3) had attempted suicide.
*All patients on the psychiatric unit received care in a safe setting.
Findings include:

1. Observation tour on 11/23/15 at 3:00 p.m. of the hospital's ten bed psychiatric unit revealed several environmental hazards for patients that might attempt suicide by hanging or self-harm. The observation tour revealed:
*The public toilet used by patients and visitors had exposed plumbing and the handwashing sink had a long single handle to turn the water on and off.
*The activity room had a media cart with a long extension cord wrapped around the handle used to push the cart.
*All beds on the unit had four siderails that could be lowered and raised. The two upper siderails had bed controls that lowered and raised the bed.
*Review of three patient rooms revealed long exposed toilet plumbing, long blade handles to turn the water on and off, a long neck faucet, and long water control handles in the showers.

Interview with the unit manager at the time of the above observations revealed:
*That was the set-up in all patient rooms. She confirmed there was a potential suicide risk by hanging from the shower, faucet, and toilet plumbing fixtures.
*A Pro-Active Safety Assessment - Suicide Prevention form had been completed on the unit in November 2014 and again in November 2015.
*Changes had been made to the unit's environment:
-Extra cameras had been installed and some had been adjusted to get a better view of the unit.
-Elbow brackets on the doors used to keep them opened had been removed.
-The electrical cords on the beds had been shortened.
-Locks had been removed from the bathroom doors.

Review of the provider's 11/5/14 Pro-Active Safety Assessment - Suicide Prevention form revealed the "current risks":
"1. Bathroom doors - should be locked unless contraindicated by state law - we do not lock bathroom doors, however we do have exposed toilet pipes and flush handle that pose a risk along with shower knobs in the bathroom." The bathroom locks were removed on January 27, 2015.
"2. Bedroom doors should swing out into the corridor to prevent patient from barricading themselves in the room - Most patient doors swing inward - capable of blocking the door with heavy furniture."
"3. Use suicide-proof door handles or push pull latches installed upside down."
"4. Door hinges should be non-rising pin type with "hospital tip" - this was present in the 266 room with a bed, most other patient rooms had regular door hinges." The undated ProActive Risk Assessment Action Plan indicated removal of the hinges on top of door had been completed 3/1/15.
"5. Manual beds are preferred. If electrical beds are to be used, provide key lockout switches so only staff can operate beds. All electrical cords should be secured and shortened. We have all electrical beds with controls and electrical cords exposed."
"6. Have non-accessible solid ceilings. Kitchen and halls have accessible ceilings. Consider locking kitchen unless staff are present and purchasing additional cameras for hallways that do not currently have camera coverage. Staff name [____] has work order in for more cameras- we have cameras just need to be installed."
"7. Mirrors - polycarbonate or polished metal type only. No glass mirrors. Secure with tamper-resistant screws or recess them into the wall. Most patient rooms have glass mirrors." The undated ProActive Risk Assessment Action Plan indicated the maintenance staff had inspected and noted all mirrors were made of nonbreakable material.
"8. Light fixtures should be secured with tamper-resistant screws. No glass components in any fixtures. If not recessed, cover light fixtures with safety cages to minimize damage or removal. Shatter-resistant light bulbs. Most patient rooms have bulbs easily accessible including the kitchen. Patient room #266 room with bed did not have easily accessible bulbs."
"9. The heat registers in most patient rooms are a cutting risk. Some rooms the wire mold conduit would be a hanging/choking risk." The undated ProActive Risk Assessment Action Plan indicated this had been corrected on 3/15/15.
"10. Handrails in hallways are a hanging/choking risk."
"11. Door to kitchen is high risk - magnet closer, knob, hinge."
"12. TV room - mini blind with no cord- however consider the other cords within the blind."
"13. Kitchen blinds- plastic and sticks within the blind. Consider removing and tinting windows."
"14. An upgraded camera system so more areas are accessible by camera." Action was completed 2/1/15.

The provider's 11/5/14 undated Pro-Active Safety Assessment - Suicide Prevention form revealed the below listed immediate fixes had occurred:
"1. 2N06 Hall Bathroom - remove the privacy curtain. (Done)
2. Lock top cupboards in kitchen (Done)
3. Have light removed above kitchen sink
4. Remove window latches
5. Remove plastic emesis bags from rooms (Done)
6. Remove closet doors in patient rooms
7. Remove bedside waste bags. (Done)"

Review of the ProActive Risk Assessment Action Plan revealed:
1) Bathroom doors: room 266 had door that swung both ways, was budgeted for 3/31/15, and moved to fiscal year (FY) 2017 budget.
2) Patient room doors: create doors that swing both ways, budgeted for 3/31/15 remodel, and moved to FY 2017 budget.
3) Suicide proof door handle latches: remove door handles, etc with possible high risk for self harm, budgeted for remodel 3/31/15, and moved to FY 2017 budget.
4) Manual beds: replace hospital beds with box beds in some rooms, budgeted for remodel 3/31/15, and moved to FY 2017 budget.
5) Non-accessible solid ceilings: build new unit and was budgeted for year 2019.
6) Light fixtures: shatter proof light fixtures, price and budget for 3/31/15, and moved to FY 2017 budget.
7) Handrails: price and budget for 3/31/15. Moved to FY 2017 budget.
8) Doors: remove possible self harm risks. Removed hinge on top of door completed 3/1/15.
9) TV room and kitchen blinds: tint windows. Price and budget for 3/1/15 and moved to FY 2017 budget.

Review of the provider's 11/17/15 Pro-Active Safety Assessment - Suicide Prevention form revealed there were twelve environmental items listed for being a risk to patients. The list had not been updated to remove at risk items that had been corrected as noted on the 11/5/14 Pro-Active Safety Assessment - Suicide Prevention form.

Interview on 11/24/15 at 7:35 a.m. with the unit manager revealed:
*She had completed the Pro-Active Safety Assessment - Suicide Prevention form dated 11/5/14 and 11/17/15.
*The Pro-Active Safety Assessment - Suicide Prevention form dated 11/5/14 had been presented at the Risk Management Patient Safety Committee Meeting.
*Most of the items identified on the Pro-Active Safety Assessment - Suicide Prevention form were budgeted for 2017.
*The Pro-Active Safety Assessment - Suicide Prevention form dated 11/17/15 had just been completed and had not been presented to the Risk Management Patient Safety Committee yet.

Interview and review on 11/24/15 at 2:55 p.m. with the medical director of the behavioral health unit, unit manager, and the director of quality regarding the Pro-Active Safety Assessment - Suicide Prevention risk assessments dated 11/5/14 and 11/17/15 revealed:
*The environmental risk factors for patients attempting suicide by hanging had not been mitigated (fixed).
*The medical director stated the lists needed to be prioritized and 2017 was not an acceptable date to implement changes. Changes needed to occur sooner.
*Door hinges had been removed.
*Extra cameras had been installed.
*To fix patient bedroom doors and the bathroom doors to prevent suicide risks might cost at least $3,500 per door.
*The electrical cords on the electrical beds had been shortened, they were not sure if the bottom

Based on observation, interview, and record review, the provider failed to ensure:
*Environmental safety concerns had not been addressed for three of three sampled psychiatric patients (1, 2, and 3) that had attempted suicide.
*All patients on the psychiatric unit received care in a safe setting.
Findings include:

1. Review of the medical record for patient 1 revealed he had been admitted on 11/16/15 and was discharged on 11/20/15.

Review of patient 1's history and physical report signed 11/16/15 at 10:24 p.m. revealed:
*His diagnoses were major depressive disorder and severe with psychotic features; anxiety disorder, and severe cannabis use disorder.
*The patient had attempted to strangle himself with a belt while in jail.
*He complained of "auditory [hearing] hallucinations telling him to kill himself."
*He stated over the last few months he had attempted to end his life several times.
*He denied homicidal thoughts, obsessions, compulsions, paranoia, and delusions.
*Mentally his senses were clear, oriented to person, place, and time; attention and concentration was fair; and his insight and judgement was poor.
*His plan included admission to Avera St. Luke's behavior health unit and place him on suicide precautions.

Review of patient 1's mental health assessment dated 11/18/15 at 2:36 p.m. revealed:
*At 2:00 p.m. the patient had requested Ativan (antianxiety medication) to help with the voices he was hearing. He was informed he could have Ativan in thirty minutes, and voiced his understanding.
*At 2:15 p.m. the patient call light rang at the nurses' station, staff looked at the camera monitor, and it appeared the patient was in the bathroom. Staff asked if he needed assistance and received no answer. A staff member reported they had just been in the patient's room to ask if he wanted to attend group, but the patient was in the bathroom.
*A registered nurse (RN) went to the patient's room, opened the door, saw a sheet with a knot draped over the closed bathroom door.
*The RN "opened the door, found the patient on the other side with the other end of the sheet tied in a knot around the patient's neck."
*"Patient was not suspended and feet were flat on the ground, but the sheet was fairly tight."
*The patient was eased to the floor, the sheet was untied and removed, and he fluttered his eyes several times before opening them.
*There was no loss of consciousness, he was orientated times three (person, place, and time), and his memory recall was immediate.
*His blood pressure was 143/77, respirations 16, pulse 90, and his oxygen saturation was 98 to 100 percent (amount of oxygen circulating in the blood).
*The patient stated "he just wanted to end it all."

2. Review of the medical record for patient 2 revealed:
*She had been admitted on 1/24/15 and was discharged on 1/25/15.
*The behavioral health team conference had identified suicidal ideation as a problem.
*The patient was on every fifteen minute close observation checks.

Review of the behavior management ability note dated 1/24/15 at 4:45 p.m. revealed:
"At 15:30 [3:30 p.m.] she asked to call her sister. At this time a note was found in front of the door of her room and the door was closed. The note stated that I'm sorry IT's too late and she signed it. She had lodged 2 chairs up against the bed and the door. She tied the bed sheet around her neck twice and had it twisted hard and tight around her neck. She was pulling on the sheet with her right arm and had her back up against the foot of the bed. She had her eyes closed and her hand was pulled off the sheet. She was on the verge of consciousness. The sheet was taken off her neck. She had a pulse and was breathing and shortly after within 30 secs [seconds] opened her eyes. She was mad and asked why the staff didn't wait one more minute and I would have been gone. I would have been at peace and my pain would have been gone. She described the darkness that she saw. She was angry and said how nobody cares about her and that staff is just doing her job. Reassurance and support provided."

Review of patient 2's history and physical report electronically signed on 1/24/15 revealed:
*Chief complaint: Suicidal thoughts.
*History of present illness:
-The patient had presented to the hospital's emergency department (ED) after having a seizure while in jail.
-She expressed thoughts of suicide while in the ED and was admitted to the mental health unit.
-Shortly after her arrival on the unit she had turned on her bathroom shower and blocked the door with her bed.
-"She was found lying on the floor with a sheet around her neck and the other sheet around bedpost. The nurses immediately untied the sheet. She lied on the floor for several minutes crying, stating that if she had 1 more minute she could have died."
-The patient had attempted suicide three or four times in the past. The last time was two weeks ago when she had taken a bottle of Dilantin (seizure medication) and half a bottle of Xanax (antianxiety medication).
*She had no history of mania, psychosis, but had stated anxiety and panic feelings.
*Past psychiatric history:
- Her last admission to Avera St. Luke's mental health unit was in 2011.
-She was currently taking Xanax and had used Wellbutrin (antidepressant) and Zoloft (antidepressant) in the past.
*Past medical history: Seizure disorder.
*Thought content: "Patient endorses suicidal thoughts with plan to overdose or hang herself."
*Assessment: Major depressive disorder, recurrent, severe.
*The plan for the patient was:
-Admission.
-Twenty-four hour hold.
-One-to-one observation because of recent suicide attempt.

Review of patient 2's discharge summary signed on 1/26/15 revealed the patient continued to have suicidal thoughts with plan to overdose or hang herself. "She was transferred to [hospital name] for further evaluation and management." The patient condition on discharge was listed as "The patient was discharged in need of further psychiatric care."

3. Review of the medical record for patient 3 revealed:
*He had been admitted on 2/11/15 and was discharged on 2/12/15. Further review of the medical record revealed:
*The behavioral health team conference dated 2/12/15 had identified suicidal ideation as a problem.
*The patient was on every fifteen minute close observation checks.
*He was on a twenty-four hour hold.

Review of patient 3's history and physical report signed 2/11/15 at 8:37 p.m. revealed:
*The patient had a history of depression and had a lot of stressors in the past few months.
*He had been admitted to Avera St. Luke's mental health unit and Human Services Center in the past.
*He denied suicidal thoughts, homicidal thoughts, hallucinations, obsessions, compulsions, and there was no evidence of paranoia or delusions.
*He was oriented, memory intact, attention and concentration was fair, and his insight and judgment was limited.
*His assessment was recurrent, severe major depressive disorder, history of alcohol use disorder, and personality disorder.
*The plan was to admit him to Avera St. Luke's mental health unit and was on suicide precautions.

Review of patient 3's mental health unit assessment documented on 2/12/15 at 10:45 a.m. revealed:
*During a fifteen minute check a nurse aide had asked the registered nurse (RN) to check on the patient.
*The RN saw a knotted towel hanging at the top of the bathroom door, pushed the door open with some resistance, and found the patient standing on the toilet with a towel wrapped around his neck as a noose.
*A rapid response and code yellow was called.
*The patient was alert, tearful, red faced, unwilling to follow directions, refused to allow the staff to loosen the noose, and was restrained by the staff.
*The patient continued to fight the staff, the police were called, and the patient was tased (to shoot with a Taser gun) by the police.
*The patient was medically cleared, was taken to jail, and the psychiatrist was notified.

4. Interview and review on 11/24/15 at 9:40 a.m. and 2:30 p.m. of patients 1, 2, and 3's medical records with the unit manager revealed:
*She had completed a Pro-Active Risk Safety Assessment - Suicide Prevention form for the unit's environ