HospitalInspections.org

Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure that patients were visually monitored for safety as required and that staff assigned to monitor the patients were aware of the patients' suicide risks. See deficiency A-144-A.

2. The hospital failed to ensure that 1:1 intervention assessments were completed by the nurse as ordered, to evaluate the patient's needed for continued monitoring. See deficiency A-144 B.

3. The hospital failed to ensure that a patient observational rounds were documented/completed timely as required. See deficiency A-144 C.

4. The hospital failed to ensure that a suicide risk level was reassessed after a patient attempted suicide.See deficiency A-144-D.

5. The hospital failed to ensure that patient was medically evaluated after a suicide attempt. See deficiency A-144-E.

6. The hospital failed to ensure that routine room and unit checks were completed as required. See deficiency at A-144-F.

The immediate jeopardy (IJ) was identified at 7/12/2024 at 42 CFR 482.13 Patient Rights, due to the hospital's failure to ensure appropriate supervision for 2 of 2 patients (Pt. #1 and Pt. #11) on high suicide risk. Subsequently, four attempts of suicide attempts occurred. The IJ was announced on 7/12/2024 at 1:35 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Director of Risk, Manager of Risk, Director of Clinical Services, and Director of Marketing. The IJ was not removed by the survey exit date of 7/12/2024.

A. Based on document review, video review, and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #11) patients reviewed for suicide attempt, the hospital failed to ensure that patients were visually monitored for safety as required and that staff assigned to monitor the patients were aware of the patients' suicide risks. Subsequently, 4 incidents of suicide attempts occurred.

Findings include:

1. The hospital's policy titled, "Observations, Patient" (dated 6/2022) required, "Documentation of the observation is to be completed once the patient has been observed ... 7. Q 5 Minute Rounds: ...During times of personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the slightly opened bathroom door ... 8. 1:1 Observation: ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times. There should be nothing between the patient and assigned staff ..."

2. The Hospital's policy titled, "Suicide Risk Assessment" (revised 11/2023) required, "Suicide risk, level of observations and/or placement of Suicide Precautions will be communicated to all staff ..."

3. The clinical record of Pt. #1 was reviewed. On 6/15/2024, Pt. #1 was admitted with a diagnosis of major depressive disorder. The clinical record included:

- The On-call Psychiatrist/Chief Medical Officer (MD #2) physician's order dated 06/16/2024 at 9:53 PM, included, " ...Observation Q 15 [every fifteen-minutes] ...suicide high now ...".

-On 06/25/2024 at approximately 2:45 PM, Pt. #1's incident report dated 06/21/2024 at 2050 [8:50 PM] was reviewed and included, " ...Type of incident: Suicide Attempt; Location: 3 East Patient [Pt. #1's] Room Doorway; Fact Summary: At approximately 2050 [8:50 PM] during med (medication) pass, Behavioral Health Associate[BHA/E #6] screamed that we need a nurse. Upon arriving [Pt. #1] was found on the floor, in the doorway, unresponsive, face was flushed, and clothing was soaked. Patient [Pt. #1] noted to have a pulse and noticed green string around the neck. Nurse [E #2] cutting the string while myself [E #1] and BHA [E #6] was pulling the string away from her [Pt. #1's] neck. [Pt. #1] was given paper scrubs, place on 1:1, Q5's observations and management notified and doctor ...Was client injured: Yes ...redness around neck .... If yes, was outside medical treatment required? No ...Actions taken: Placed on 1:1 ...".

4. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder.

- Pt #11's suicide risk assessment on admission intake (6/27/2024 at 2:52 AM) indicated that Pt #11 was a high risk for suicide. Physician's (MD #4) admission orders (6/27/2024 at 3:28 AM) included precautions for high suicide risk, assault, and elopement with Q5 (every 5) minute observations.

- Nursing House Supervisor E#17's note, dated 6/27/2024, included "At approximately 11:40 [AM], BHA completing [Pt #11's] q5 observation round, BHA knocked on bathroom door, no response heard. BHA opened door pt laying on the bathroom floor with paper scrub pants tied around pt neck. BHA called for assistance; staff immediately removed the paper scrub pants around pt's neck."

- The Patient Observation Rounding sheet, dated 6/27/2024, indicated that Pt. #11 was noted to be in the bathroom at 11:25 AM, 11:30 AM, and 11:35 AM by BHAs E#19 and E#24. No round was document at 11:40 AM (approximate time of incident).

- The record indicated Pt. #11 was placed on 1:1 monitoring and linen restrictions after the incident on 6/27/2024. These orders were discontinued on 6/29/2024 at 2:21 PM by the Registered Nurse (RN/E #23) per verbal order of MD #3, and Pt. #11's level of monitoring was changed to Q5 minutes.

- Nurse E#18's progress note, dated 7/2/2024, included "Around 2:35 PM, [Pt. #11] went into the community bathroom. After two minutes we heard patient coughing, RN knocked on door and patient did not respond. RN opened the door and saw patient on the ground with [Pt. #11's] pants tied around [Pt. #11's] neck. RN told [Risk Management E#15] to call a code. RN and BHA [E#20] turned [Pt. #11] over to untie the pants."

- The record indicated that Pt. #11 was placed on 1:1 monitoring, linen restrictions, and hallway bathroom restriction after the incident on 7/2/2024.

5. On 07/10/2024, Pt. #11's incident report dated 06/27/2024 at 11:40 AM was reviewed and included, " ...Type of incident: Suicide Gesture; Location: Bathroom; Fact Summary: ... (Pt. #11) observed in bathroom with paper pants wrapped around (Pt. #11's) neck ...removed paper pants from (Pt. #11's) neck, assessed pulse. Vitals obtained, were within normal limit. (Pt. #11) sat up, (Pt. #11) refusing to answer assessment and CSSR [Colombia-Suicide RiskRating Scale] questions. (Pt. #11) immediately placed on 1:1. Medical provider notified, gave order to send to (outside hospital). Psych (psychiatric) provider gave order 1:1, linen restriction, blocked room ...Evaluation: was injury observed: No ...was outside treatment necessary: Yes ...Notification: ...6/27/2024 at 11:45AM Physician (MD #3) ..."

6. On 07/10/2024, Pt. #11's incident report dated 7/02/2024 at 1435 (2:35 PM) AM was reviewed and included, " ...Type of incident: Suicide Attempt; Location: Community Bathroom; Fact Summary: ... (Pt. #11) went into community bathroom after 2 mins (minutes) we (staff) heard (Pt. #11) coughing. RN knocked on door and no response. RN opened door and found (Pt. #11) on the ground with pants tied around neck. RN and BHA untie pants. RN stayed with (Pt. #11) and took vitals. Vitals WNL (within normal limits). (Pt. #11) placed on 1:1, linen restriction and placed in paper scrubs ...Evaluation: was injury observed: No ...was outside treatment necessary: No ...Notification: ...7/02/2024 at 1440 (2:40PM) Physician (MD #3)."

7. On 07/11/2024, Pt. #11's incident report dated 07/10/2024 at 2000 (8:00 PM) was reviewed and included, " ...Type of incident: Suicide Attempt; Location: (Pt. #11's Room); Fact Summary: (patient) ran up to nurse's station yelling to "call a code" there is someone choking themselves". (Pt. #11) was found (Pt. #11) on the bathroom floor with (Pt. #11's) scrub pants tied around (Pt. #11's) neck. Per (E #25/Behavioral Health Associate/1:1 monitor), (E #25) allowed (Pt. #11) to use the bathroom unattended. (E #25) found (Pt. #11) strangling self ...Interventions/Treatment: ...PRN (as needed) medication ...place on 1:1 ...verbal de-escalation ...Evaluation: was injury observed: No ...was outside treatment necessary: No ...Notification: ...7/10/2024 at 8:00 PM Physician (MD #4)."

8. On 7/10/2024 hospital video footage was reviewed around time of incidents on 6/27/2024 between 11:10:00 AM and 1:15:00 PM; on 7/02/2024 between 2:20:00 PM and 2:40:00 PM. The video footage confirmed that observational monitoring was not performed as ordered, Q5 and 1:1, while Pt. #11 was in the bathroom.

9. On 7/10/2024 an interview with the BHA (E #19/ Incident #1 on 6/27/2024) was conducted. E#19 stated that if the patient remains in the bathroom during the next round, they will knock and listen for a response from the patient. E#19 stated that they don't have to visualize the patient in the bathroom unless they are 1:1.

10. On 7/10/2024, an interview with the BHA (E #20/ Incident #2 on 7/02/2024) was conducted with BHA E#20 on 7/10/2024. E#20 stated that E#20 was not told about Pt. #11's prior suicidal gestures. E#20 stated that when patients are on Q5 minute monitoring, the door does not need to be open, and staff do not have to stay by the bathroom.

11. On 7/11/2024 at approximately 11:46 AM, an interview with the BHA (E #25/Incident #3 on 7/10/2024) was conducted. E #25 stated that (E #25) was assigned as (Pt. #11's) 1:1 monitor for the evening shift (7:00 PM - 7:00 AM) on 7/10/2024. E #25 stated that (E #25 and Pt. #11) were in Pt. #11's room, (Pt. #11) had to use the bathroom, and (E #25) allowed (Pt. #11) to go into the bathroom unattended. E #25 stated that approximately two to three minutes had passed and (E #25) did not hear (Pt. #11). E #25 stated that (E #25) stood up, turned the bathroom light on, and found (Pt. #11) on the ground with paper scrubs around (Pt. #11's) neck, choking self. E #25 stated that (E #25) should have been in the bathroom with (Pt. #11) as 1:1 monitoring is constant visualization. E #25 stated that was the first time working with Pt. #11 and E#25 was taking over 1:1 for Pt. #11 from another BHA. E#25 stated that E#25 was not told of Pt. #11's previous suicide attempts in the bathroom when E#25 took over 1:1 monitoring for Pt. #11 and E#25 was not aware why Pt. #11 was on 1:1 prior to the incident on 7/10/2024.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #11) record reviewed for patients placed on 1:1 (one-to-one) monitoring, the hospital failed to ensure that 1:1 intervention assessments were completed by the nurse as ordered, to evaluate the patient's needed for continued monitoring. This had the potential to affect all patients on 1:1 monitoring for safety concerns.

Findings include:

1. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder.

- Pt #11's suicide risk assessment on admission intake (6/27/2024 at 2:52 AM) indicated that Pt #11 was a high risk for suicide. Physician's (MD #4) admission orders (6/27/2024 at 3:28 AM) included precautions for high suicide risk, assault, and elopement with Q5 (every 5) minute observations.

- Nursing House Supervisor E#17's note, dated 6/27/2024, included "At approximately 11:40 [AM], BHA [behavioral health associate] completing [Pt #11's] q5 observation round, BHA knocked on bathroom door, no response heard. BHA opened door pt laying on the bathroom floor with paper scrub pants tied around pt neck. BHA called for assistance; staff immediately removed the paper scrub pants around pt's neck."

- Physician orders, dated 6/27/2024 (after the incident), included 1:1 Observation monitoring and One to One Clinical Intervention Worksheet to be completed by nurse every 4 hours until the 1:1 observation is discontinued.

- One-to-One Intervention worksheets from 6/27/2024 to 6/29/2024 were reviewed and lacked documentation that these assessments were completed every 4 hours as required, to determine if Pt. #11 should continue on 1:1 or possibly be lowered in terms of level of observation. The last completed worksheet, dated 6/28/2024 at 4:04 AM, indicated that Pt. #11 was still in need of 1:1 monitoring.

- The record indicated that the 1:1 order was discontinued on 6/29/2024 at 2:21 PM by the Registered Nurse (E #23) per verbal order of MD #3, and Pt. #11's level of monitoring was changed to Q5 minutes.

- Subsequently, Pt. #11 made another attempt to tie pants around Pt. #11's neck on 7/2/2024 and Pt. #11 was placed on 1:1 monitoring again and remained in effect on 7/9/2024.

- One-to-One Intervention worksheets from 7/2/2024 to 7/9/2024 were reviewed and lacked documentation that these assessments were completed every 4 hours as required between 7/2/2024 at 4:56 to 7/3/2024 at 7:59 AM; 7/3/2024 at 4:18 PM to 7/5/2024 at 12:40 AM; 7/5/2024 at 12:40 AM to 7/7/2024 at 12:11 AM; between 7/7/2024 12:11 AM to 8:55 AM, and none were completed on 7/8/2024.

2. An interview was conducted with Registered Nurse (E#23) on 7/11/2024, at approximately 10:20 AM. E#23 did not recall talking to MD#3 about discontinuing Pt. #11's 1:1. E#23 stated that E#23 thought that Pt. #11 was on 1:1 due to aggression with peers and was not related to the strangling incident on 6/27/2024. E#23 stated that as the nurse, E#23 assesses the patients everyday and asks if they have thoughts of self-harm or behaviors. E#23 stated that the one-to-one intervention worksheet should be completed every 4 hours by the nurse to see how the patient is progressing and if there are any changes. E#23 stated that it is ultimately up to the psychiatrist what level of observation the patient should be on. E#23 stated that E#23 has never suggested any patient come off 1:1 monitoring after giving the physician E#23's assessment of the patient.

C. Based on document review and interview, it was determined that for 4 of 4 (Pts. #11, Pt. #14, Pt. #15, and Pt. #16) patient records reviewed for observational rounds, the hospital failed to ensure that patient observational rounds were documented/completed timely as required.

Findings include:

1. The hospital's policy titled, "Observations, Patient" (dated 6/2022) required, " ...Staff documents all levels of observation on each patient's observation form which becomes part of the patient record. Each entry is to include the following: i. Level of observation, ii. Precautions, iii. Location, iv. Behavior, v. Activity, vi. Time, vii. Staff Initial and Signature ... Documentation of the observation is to be completed once the patient has been observed ... Documentation of 1:1 observation occurs q 15 [every 15] minutes even though the patient is being observed continuously ..."

2. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. The clinical record included the following:

-Physician orders indicated that Pt. #11 was on Q5 (every 5 minute) monitoring from 6/29/2024 at 2:25 PM until 7/2/2024 at 2:54 PM. Pt. #11 was placed on 1:1 monitoring on 7/2/2024 at 2:54 PM following a second attempt to tie clothing around Pt. #11's neck.

-Patient Observational Rounds from 6/27/2024 to 7/9/2024 at 12:00 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times:

- Q5 minute rounding on 6/30/2024 at 12:25 AM, 12:40 AM, 9:10 AM, 11:30 AM, 12:55 PM, 5:35 PM, 6:25-6:55 PM, 7:15 PM, and 11:00 PM were missed.

- Q5 minute rounding on 7/1/2024 at 12:55 AM, 3:45 AM, 4:00 AM, 900 AM, 3:50 PM, 7:00 PM, 7:35 PM, 7:40 PM, 8:05 PM-8:20 PM, and 10:15 PM were missed.

- 1:1 patient observation documentation on 7/2/2024 was missed between 4:40 PM-7:25 PM, between 8:25 PM to 8:50 PM, and between 10:40 PM to 10:55 PM.

2. The clinical record of Pt. #14 was reviewed on 7/10/2024. Pt. #14 was admitted on 6/30/2024 at 11:52 PM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder.

-Physician observation orders indicated that Pt. #14 was on Q5 monitoring from 7/01/2024 at 12:58 AM until 7/3/2024 at 8:07 AM, Q15 every 15 minutes) monitoring from 7/03/2024 at 8:07 AM until 7/05/2024 at 9:52 PM, Q5 at 7/05/2024 at 9:45 PM to 7/08/2024 at 12:43 PM, and Q15 from 7/08/2024 at 12:42 PM to current (as of 7/10/2024 at 3:00 PM).

-Patient Observational Rounds from 7/01/2024 to 7/10/2024 at 1:15 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times:

- Q5 minute rounding on 7/01/2024 at 3:45 AM, 4:10 AM, 6:45 AM, 11:10 AM, 1:25 PM, 3:55 PM, 4:45 PM, 7:40 PM - 7:50 PM, 8:00 PM - 8:30 PM, 8:40 PM, 11:10 PM, and 11:40 PM were missed.

- Q5 minute rounding on 7/02/2024 at 12:30 AM, 1:55 AM, 6:25 AM, 9:10 AM, 10:55 AM, 2:35 PM, 2:55 PM, 7:05 PM, 7:15 PM, 8:15 PM, and 8:20 PM were missed.

- Q5 minute rounding on 7/05/2024 at 9:45 PM to 7/06/2024 at 4:00 AM was conducted every 15 minutes, not every 5 minutes as required.

- Q5 minute rounding on 7/06/2024 at 5:05 AM, 6:10 AM, 11:45 AM, and 4:05 PM to 4:20 PM were missed.

- Q5 minute rounding on 7/07/2024 at 2:40 PM, 3:00 PM, 4:45 PM, 9:30 PM, 10:05 PM, 10:20 PM 11:40 PM, 11:55 PM were missed.

- Q5 minute rounding on 7/08/2024 at 2:55 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:40 AM, 4:50 AM, 6:25 AM were missed.

3. The clinical record of Pt. #15 was reviewed on 7/10/2024. Pt. #15 was admitted on 7/04/2024 at 6:24 PM, to the 5th Floor Adolescent Boys Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. The clinical record included the following:

-Physician observation orders indicated that Pt. #15 was on Q5 monitoring from 7/04/2024 at 7:20 PM until 7/05/2024 at 2:26 PM and Q 15 monitoring from 7/05/2024 at 2:26 PM to current (as of 7/10/2024 at 3:00 PM).
Patient Observational Rounds from 7/04/2024 to 7/10/2024 at 1:15 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times:

- Q5 minute rounding on 7/04/2024 at 8:15 PM to 7/05/2024 at 4:15 PM was conducted every 15 minutes, not every 5 minutes as required.

4. The clinical record of Pt. #16 was reviewed on 7/10/2024. Pt. #16 was admitted on 7/09/2024 at 5:23 PM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder.The clinical record included the following:

-Physician observation orders indicated that Pt. #16 was on Q5 monitoring from 7/09/2024 at 10:37 PM to current (as of 7/10/2024 at 3:00 PM).

-Patient Observational Rounds from 7/09/2024 to 7/10/2024 at 1:20 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times:

- Q5 minute rounding on 7/09/2024 at 10:35 PM and 10:55 PM were missed
.
- Q5 minute rounding on 7/10/2024 at 12:20 AM, 1:45 AM, 2:40 AM, 2:55 AM, 6:20 AM, 6:35 AM, 9:05 AM, 10:20 AM, 10:30 AM, 11:25 AM, 12:05 PM, 12:20 PM, and 1:10 PM were missed.

5. An interview was conducted with the Informational Technology Specialist (E #28) on 7/11/2024, at approximately 11:00 AM. E #28 stated that staff are required to document rounds when they are within range of the patient at the interval that is ordered by the physician (i.e. Q5 or Q15). E #28 stated that if the patient is on 1:1 monitoring, the round sheet will show an "(M)" to indicate that it was a 1:1 staff was doing the rounds. E #28 stated that 1:1 staff are expected to document an observation of the patient at least every 15 minutes. E #28 stated that if they are late or not within range, the round will be missed on the log. E #28 stated that it is the registered nurses task to update observational monitoring in the computer system to reflect physician order.



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D. Based on document review and interview, it was determined that for 1 of 5 patients (Pt. #1) clinical record reviewed for suicide high risk assessments and reassessments, the hospital failed to ensure that a suicide risk level was reassessed after a patient suicidal attempt as required.

Findings include:

1. On 06/26/2024 at approximately 2:40 PM, the hospital's policy titled, "Suicide Risk Assessment" dated 06/2022 was reviewed and included, " ...Facility screens all patients for suicidal ideation using validated screening tool ...Columbia Suicide Screen Risk Scoring (CSSRS) process is utilized for every patient upon admission ...initially screened in Intake to identify suicide ideation ... Reassessment: Patients ...may be reassessed using the SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) protocol with CSSRS at any point during hospitalization, such as in the event of a change in suicidality ...suicide attempt ..."

2. On 06/26/2024 at approximately 3:00 PM, the hospital's Suicide Risk Assessment Practitioner Examples (date unknown) was reviewed and included, " ...Suicide High Risk: 16 or above (ideation intensity) Expected observation level 1:1 (or Q5[every 5 minutes] if no ligature risk); Moderate Risk: 6 -15; Low Risk: 5 or below..."

3. On 06/25/2024 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 at 9:55 PM with a diagnosis of major depressive disorder. Pt. #1's clinical record included the following:

-The initial psychiatric evaluation by Attending Psychiatrist (MD #1) dated 06/16/2024 at 1:17 PM, included, " ...history of MDD [major depressive disorder] presenting for increased SI [suicidal ideations] after failing residential treatment at [name of residential facility] ...worsening moods ...since medications adjusted ... led to increased depressive symptoms, feelings of rejections, and increased SI [suicidal ideation] ......Precautions: SI [suicidal ideations precautions]..."

-The Intake Assessment note dated 06/15/2024 at 8:55 PM, included, " ...Chief Complaint: Pt. [Pt. #1] note that ...feels problems began recently due to psychiatrist changing medications ...drs. [doctors] removed all medications due to frequent seizures that have been occurring ...pulled medications 4-5 days ago ...been decompensating ...and been breaking down ...feels more isolated and suicidal ...dreams of committing suicide ...stress has been causing to feel suicidal later ...was sent out (from residential facility) due to increased SI [suicidal ideation] with a plan does have hx [history] suicidal ideation...Risk Factors: ... Suicidal Thoughts: Yes ...Thoughts about Plans, and Suicidal Intent: Yes ...Frequency: Many times each day ...Duration: 4 -8 hours/most of day ...Controllability: Unable to control thoughts ...Reasons for Ideation: Equally to get attention, revenge or a reaction from others and to end/stop the pain ...Risk Stratification: High suicide risk: Suicidal ideation with intent or intent with plan in past month ...Risk Level" High Suicide Risk ...self admits high levels of suicidality ...Score: 22 [High Risk 16 or above - expected observation 1:1 (or Q5 if no ligature risk ..."

-The registered nurse (E #1) [Addendum] to progress note dated 06/22/2024 at 6:26 AM, included, " ...Approximately 2050 [8:50 PM] during med. [medication] pass BHA [Behavioral Health Associate- E #6] scream that we need nurse. Upon arriving [Pt. #1] was found on the floor, in [Pt. #1's] doorway, unresponsive, face was flushed, and clothing was soaked ...noted to have pulse and noticed a green string around the patient neck ...Nurse [E #2] cut the string while myself [E #1] and BHA [E #6] was pulling the string away from [Pt. #1's] neck ... Patient [Pt. #1] was assessed and vitals were WNL [within normal limits] and red marking was noted on patient neck; after green string was cut off ...began to cough and turned to side ...staff assisted [Pt. #1] to the bed ...Placed on 1:1 and Q5 for observation. Notified on-call physician/Chief medical officer (MD #2) ...patient [Pt. #1] resting comfortable throughout the night and did not display any s/s [signs and symptoms] of anxiety ...remains on 1:1 [one-to-one] and Q5 [every 5 minutes] for safety." The registered nurse progress notes lacked the suicide risk re-assessment after a suicidal attempt.

4. On 06/26/2024 at approximately 9:00 AM, the Registered Nurse (E #1) that took care of the patient (Pt. #1) on 06/21/2024 during the incident was interviewed. E #1 stated that it all happened so fast. E #1 stated that (E #1) forgot to complete the re-assessment of suicide risk after the suicide attempt.

5. On 06/26/2024 at approximately 12:30 PM, the Nurse Manager (E #4) was interviewed. E #4 stated that the suicide risk assessment and scoring should be done upon admission and re-assessment after any event. E #4 acknowledged that there was no suicide risk assessment and scoring done after the suicide attempt by Pt. #1 on 06/21/2024.

E. Based on document review and interview it was determined that for 1 of 5 patient (Pt. #1) clinical record reviewed for suicide high risk, the hospital failed to ensure that patient was medically evaluated after a suicidal attempt.

Findings include:

1. The hospital's policy titled, "Medical Emergency" dated 6/2022 was reviewed and included, "...A medical emergency is an event requiring rapid assessment and intervention ...cardiac arrest ...change in level of consciousness ...1. The first staff to recognize ...summon assistance by loudly calling "Code Blue," "Medical Emergency" or "Help" ...Yell "Code Blue" ...transport emergency medical cart ...call the on-call medical practitioner ...Dial 911 for EMS (emergency medical system) as directed by the Registered Nurse or practitioner ...contact attending psychiatrist/designee ..."

2. On 06/25/2024, Pt. #1's incident report dated 06/21/2024 at 2050 [8:50 PM] was reviewed and included, " ...Type of incident: Suicide Attempt; Location: 3 East Patient [Pt. #1's] Room Doorway; Fact Summary: At approximately 2050 [8:50 PM] during med pass, BHA (Behavioral Health Assistant/E #6) screamed that we need a nurse. Upon arriving [Pt. #1] was found on the floor, in the doorway, unresponsive, face was flushed, and clothing was soaked. Patient [Pt. #1] noted to have a pulse and noticed green string around the neck. Nurse [E #2] cutting the string while myself [E #1] and BHA [E #6] was pulling the string away from her [Pt. #1's] neck. [Pt. #1] was given paper scrubs, place on 1:1, Q5's observations and management notified and doctor ...Was client injured: Yes ...redness around neck .... If yes, was outside medical treatment required? No ...Actions taken: Placed on 1:1 ..."

3. On 06/25/2024, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 at 9:55 PM with a diagnosis of major depressive disorder. Pt. #1's clinical record included the following:

-The initial psychiatric evaluation by Attending Psychiatrist (MD #1) dated 06/16/2024 at 1:17 PM, included, " ...history of MDD [major depressive disorder] presenting for increased SI [suicidal ideations]after failing residential treatment at [name of residential facility] ...worsening moods ...since medications adjusted ... led to increased depressive symptoms, feelings of rejections, and increased SI [suicidal ideation] ...increased SI in dreams and increased...Precautions: SI [suicidal ideations precautions] and AP [assault precautions] ..."

-The emergency department physician notes from (the ED Acute Care Hospital) dated 06/22/2024 at 2:00 PM, included, "Chief complaint: suicidal attempt at [the Hospital] last night by hanging self with a scrub strings, came in for wellness check, denies chest pain ...as per report staff found the patient [Pt. #1] unresponsive with low blood pressure and they had to do CPR [cardio-pulmonary resuscitation] after which the patient [Pt. #1] regained consciousness and was sent here today for check-up ...per facility patient [Pt. #1] had moment of unresponsive, unclear if pt. [Pt. #1] really lost pulses, but was given chest compressions. [Pt. #1] did not go to the hospital when this happened last night ...normal vital signs while in the emergency department, complaining of throat pain and voice hoarseness, no difficulty swallowing or difficulty breathing."

Pt. #1 was sent to the Emergency Department on 6/22/2024 at 2:00 PM, to be medically evaluated, approximately 17 hours after suicidal attempt that resulted in a period of unconsciousness.

4. On 06/25/2024 at approximately 2:25 PM, the Attending Psychiatrist (MD #1) was interviewed. MD #1 stated that (MD #1) was not sure why (Pt. #1) was not sent out for medical evaluation to the nearby emergency room. MD #1 stated that (MD #1) on 06/22/2024 at approximately 11:15 AM, upon assessing the patient ordered to transfer (Pt. #1) for medical evaluation. MD #1 stated that Pt. #1 was complaining of throat pain, and hoarseness of voice was noted.

5. On 06/26/2024 at approximately 9:00 AM, the Registered Nurse (E #1) that took care of the patient (Pt. #1) on 06/21/2024 during the incident was interviewed. E #1 stated that (E #1) called the on-call physician (MD #2) and explained about the incident. E #1 stated that MD #2 advised to place (Pt. #1) on one-to-one monitoring with a sitter at the bedside. E #1 stated the physician (MD #2) did not order to transfer (Pt #1) to the emergency room for medical evaluation.

6. On 06/26/2024 at approximately 2:00 PM, the Chief Medical Officer/On-Call Physician (MD #2) was interviewed. MD #2 stated that the staff did not tell (MD #2) that chest compressions were started on Pt. #1. MD #2 stated that the nurse (E #1) had reported that Pt. #1 was doing fine and did not have any difficulty breathing or swallowing.

F. Based on document review and interview it was determined that for 1 of 3 Patient Care Units (3 East: Adult Female Unit) reviewed for Environmental and Contraband rounding, the hospital failed to ensure that routine room and unit checks were completed as required. This has the potential to affect all patients on census on this unit.
Findings include:

1. On 06/26/2024 at approximately 2:45 PM, the hospital's policy titled, "Contraband" dated 06/2022 was reviewed and included, " ...Upon admission a thorough search will be made ...2. Staff will consider the following to be contraband: ... ii. Any item with strings ..."

2. On 06/26/2024 the hospital's 3 East - All Female Unit - BHA Environmental Rounds for Contraband Checks Log dated 06/18/2024 through 06/24/2024 was reviewed. The log lacked the environmental rounds documentation checks for the following dates and shifts:
- 06/18/2024 - AM (day- shift) - no environmental rounds
-06/19/2024 - AM shift - no environmental rounds
-06/21/2024 - PM (evening shift) - no environmental rounds
-06/22/2024 - PM shift - no environmental rounds
-06/24/2024 - PM shift - no environmental rounds

3. On 06/26/2024 at approximately 12:30 PM, the Nurse Manager (E #4) was interviewed. E #4 stated that the contraband checks along with the environmental rounds should have done daily one per shift, during the beginning of each shift. E #4 stated that (E #4) was not sure why contraband checks were missing for certain days as the milieu manager handles the contraband checks on all patient rooms. E #4 stated if contraband checks are not done, it could affect patient safety.