HospitalInspections.org

I. Based on document review and staff interview, the psychiatric hospital's administrative staff failed to ensure the psychiatric nursing staff provided care in a safe setting by allowing, for 60 days after Patient #4 attempted suicide, other patients to potentially bring lethal contraband onto psychiatric hospital's inpatient mental health units. Please refer to A-144 for additional information.

The cumulative effect of these failures and deficient practices resulted in the psychiatric hospital's inability to provide care in a safe setting, which could potentially resulted in the psychiatric patients killing themselves using lethal contraband the psychiatric nursing staff allowed the patients to bring onto the inpatient mental health units. The psychiatric hospital's administrative staff identified a census of 36 patients at the start of the investigation.



II. During the investigation of complaints 102800-C, 103612-C, 103631-C, and 103833-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient's Rights (42 CFR 482.13). The psychiatric hospital staff failed to take corrective action to prevent patients from bringing lethal contraband onto the inpatient mental health units after the hospital staff identified the nursing staff had allowed Patient #4 to bring lethal contraband onto the inpatient mental health unit.

1. The administrative staff failed to develop and implement a corrective action plan to ensure the nursing staff did not allow patients to bring lethal contraband onto the inpatient mental health units.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the psychiatric hospital's administrative staff on 4/27/22 at 9:02 AM. The hospital staff took action and removed the immediacy of the situation prior to the survey team exiting the complaint investigation when the hospital administrative staff took the following steps:

a. The hospital's leadership team searched all patient belongings on all patient care units for contraband, with 2 different individuals checking all patient belongings.

b. The hospital's leadership team searched all patient rooms, all activity rooms, all group rooms, all patient areas on the inpatient mental health units, and all off-unit patient spaces.

c. Ensured that nursing leadership would complete daily searches of all patient areas.

d. Implemented a second belongings search for patients in both the Intake Area and prior to patients going onto the inpatient mental health units.

e. Educated the staff on best practices for performing patient belongings searches.

f. Updated the patient belonging inventory form to specifically prompt staff to search for strings.


The following Condition level deficiency remained for the Condition of Participation for Patient's Rights (42 CFR 482.13).

Based on medical record review, document review, and staff interview, the psychiatric hospital's administrative staff failed to ensure patients admitted to the hospital had an assigned bed for 2 of 2 patients reviewed (Patient #2 and Patient #3), plus 18 additional patients identified through a review of the hospital's census from 1/1/22 to 4/19/22 . Failure to admit a patient without a bed assignment resulted in patients sleeping on a mattress on the floor which prevented the patient from having personal privacy without a clinical justification to deprive the patient of their personal privacy. The hospital's administrative staff reported a census of 36 patients on entrance.

Findings include:

1. Review of the policy "Patient Bedroom Assignments", last revised 9/2021, revealed in part, "It is the policy of [psychiatric hospital] to establish guidelines for the safe, ethical, and appropriate assignment of rooms for individuals ... Prior to the patient being accepted for admission, the Intake Department will ... contact the charge nurse on the unit to assess appropriate bed availability ... Once an appropriate and safe bed has been identified for the potential patient, the Intake staff will ... process the admission ..."

2. Review of medical records revealed:

a. On 2/24/22 at 9:00 PM, the hospital staff admitted Patient #2 to the psychiatric hospital. The hospital staff assigned Patient #2 to the "group therapy room." On 2/25/22 at 9:00 AM, the hospital staff reassigned Patient #2 to the "comfort room." On 2/26/22 at 8:30 PM, the hospital staff assigned Patient #2 to an inpatient bed (approximately 48 hours after the hospital staff first admitted Patient #2 to the psychiatric hospital).

b. On 3/22/22 at 9:52 PM, the hospital staff admitted Patient #3 to the psychiatric hospital. The hospital staff assigned Patient #3 to the "Intake Area." On 3/23/22 at 12:45 AM, the hospital staff assigned Patient #3 to the "comfort room." On 3/23/22 at 12:15 PM, the hospital staff assigned Patient #3 to an inpatient bed (approximately 12 hours after the hospital staff first admitted Patient #3 to the psychiatric hospital).


3. Review of the hospital's census from 2/1/22 through 4/19/22 revealed 18 additional patients where the hospital staff admitted the patient to the psychiatric hospital, but did not have an inpatient bed available for the patient. Instead, the hospital staff temporarily assigned the patients to a room on the inpatient unit (such as the comfort room or group therapy room) which was not designed for patients to stay in the room overnight.


4. During an interview on 4/13/22 at 12:00 PM, Mental Health Tech (MHT) A confirmed that the hospital staff had admitted patients to the psychiatric hospital without the hospital staff having a psychiatric inpatient bed available for the patient. If the hospital staff needed to admit a patient without an inpatient bed available for the patient, the hospital staff would usually assign the patient to the comfort room (a smaller room with 2 chairs, designed to allow patients to have a quiet space by themselves) or the group therapy room (a larger room with glass windows on all sides, where the hospital staff would assemble multiple patients during the day and allow the patients to engage in psychiatric group therapy).

When the hospital staff assigned a patient to either the comfort room or group therapy room, instead of an inpatient bed, the hospital staff place a mattress on the floor of the room and place sheets on the mattress. During the day, the hospital staff remove the mattress, so other patients can utilize the room for its intended purpose (instead of as a patient bedroom). During the day, if a patient assigned to the comfort room or group therapy room wanted to lay down on a bed, the patient could not lay down. If the patient wanted to use the bathroom or shower, the patient would need to use the shared hallway bathroom, but the patient would not have access to a shower.


5. During an interview on 4/13/22 at 3:30 PM, MHT B confirmed that if the hospital staff needed to admit a patient to the inpatient psychiatric unit, but the hospital did not have an open bed available for the patient, the hospital staff would admit the patient to either the comfort room or the group therapy room. The hospital staff would place a mattress on the floor of the comfort room or group therapy room. MHT B acknowledged that if the hospital staff admitted a patient to the comfort room or group therapy room, the patient would not have access to a bed during the day if the patient wanted to lay down, the patient would not have access to a private bathroom (and instead would need to use the shared hallway bathroom which the hospital staff would need to unlock for the patient). If the patient wanted to shower, the hospital staff would need to have another patient leave their room, so the patient in the comfort room or group activity room could use the shower.


6. During an interview on 4/13/22 at 2:00 PM, RN C verified that if the hospital staff needed to admit a patient to the hospital, but the hospital did not have an open inpatient bed, the hospital staff would admit the patient to the hospital and assign the patient to either the comfort room or group therapy room. Since the room was not designed for a patient to stay overnight, the hospital staff had to place a mattress on the floor at night for the patients to sleep on.


7. During an interview on 4/18/22 at 9:00 AM, the Chief Medical Officer (CMO) acknowledged the hospital staff utilized rooms which were not designed for inpatient overnight sleeping quarters to temporarily house patients. The CMO explained that housing patients in rooms not designed for overnight sleeping quarters was intended to provide a temporary solution, so the hospital staff could get the patient into the hospital and allow the hospital staff to start providing treatment to the patient.

Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to ensure the nursing staff removed potential ligature items from 1 of 1 patient (Patient #4) who attempted suicide in the inpatient psychiatric hospital. Failure to remove potential ligature items resulted in Patient #1 attempting to commit suicide by using a cord from Patient #1's sweatshirt and Patient #1 tying the cord around their neck in an attempt to commit suicide, in the inpatient mental health unit. The psychiatric hospital's administrative staff identified a census of 36 inpatients at the beginning of the survey.

Findings include:

1. Review of the "Contraband/Search Guidelines" policy, last approved 8/2021, revealed that upon admission to the inpatient mental health units, the Mental Health Technician (MHT) will search the patient's belongings. The MHT will ensure the patient's clothing has "no ties on hoodies/sweatshirts." The MHT is also required to ensure "...clothing is to be unfolded and zippers unzipped: [and] look for belts or drawstrings..."


2. Review of Patient #4's medical record revealed:

a. The hospital staff admitted Patient #4 to the psychiatric hospital on 2/22/22 for increased depression, suicidal ideation, and psychosis.

b. Registered Nurse (RN) D completed the "Standardized Intake Assessment" form on 2/22/22 at 8:31 AM. RN D documented that when Patient #4 presented to the psychiatric hospital, Patient #4 had a razor blade in their possession, which Patient #4 gave to RN D for Patient #4's safety. Additionally, Patient #4 was hearing voices commanding Patient #4 to hurt themself, Patient #4 had a plan to kill themself by stepping in front of a car, and Patient #4's thoughts of killing themself had gotten worse while Patient #4's coping mechanisms no longer helped relieve Patient #4's thoughts of killing themself. Prior to arrival at the hospital, Patient #4 had attempted to cut their wrists, resulting in superficial cuts to Patient #4's wrists.

c. Psychiatrist E ordered the nursing staff to admit Patient #4 to the psychiatric hospital's inpatient mental health unit at 8:31 AM on 2/22/22.

d. The "Patient Belongings Inventory," which the nursing staff completed on 2/23/22 at 7:00 AM, lacked documentation the nursing staff assessed Patient #4's clothing for items Patient #4 could potentially use to harm themself, including documenting what clothes the nursing staff allowed Patient #4 to keep while on the inpatient psychiatric unit or if Patient #4's sweatshirt had a string in it.
e. On 2/22/22 at 9:45 AM, RN D documented that the nursing staff should check on Patient #4 every 15 minutes, to ensure that Patient #4 was not attempting to kill themself.


3. Review of an incident report for Patient #4, created by House Supervisor O, listed the incident type as "Fall, found on floor/Unobserved". Further review of the incident report revealed that on 2/23/22 at 5:38 PM, the nursing staff found Patient #4 laying on the floor in Patient #4's room, with Patient #4's face bright red in color. House Supervisor O found that Patient #4 had tied a jacket string tightly around Patient #4's neck. Registered Nurse (RN) J removed the jacket string from Patient #4's neck and Patient #4 resumed breathing spontaneously. Patient #4 also suffered a cut on Patient #4's forehead when Patient #4 fell to the ground after Patient #4 tied the cord around their neck in an attempt to kill themself.


4. Further review of Patient #4's medical record from Hospital A revealed that the Clive Behavioral Health staff had Patient #4 taken to Hospital A following Patient #4's suicide attempt in Clive Behavioral Health. ED Physician Q documented that Patient #4 had attempted to hang themself in Clive Behavioral Health. ED Physician Q assessed Patient #4 and ordered radiologic testing to determine if Patient #4 had any internal injuries from Patient #4 attempting to strangle themself in Clive Behavioral Health. Following ED Physician Q's assessment and the radiologic testing, ED Physician Q determined Patient #4 was medically stable to return to Clive Behavioral Health.

Hospital A's Emergency Medical Services staff transported Patient #4 back to the Clive Behavioral Health. Critical Care Paramedic R documented that Patient #4 had purple bruising in the shape of a cord around Patient #4's neck and along the back of Patient #4's head. When Patient #4 attempted to commit suicide in Clive Behavioral Health, Patient #4 removed a cord from Patient #4's clothing (which the Clive Behavioral Health staff allowed Patient #4 to keep with them) and wrapped the cord around Patient #4's neck, in an attempt to commit suicide. Patient #4 lost consciousness and fell to the floor. Patient #4 struck their head on the sink while falling to the floor. Clive Behavioral Health staff found Patient #4 on the floor.


5. During an interview on 4/19/22 at 10:50 AM, RN D indicated RN D performed the admission assessment on Patient #4 when they arrived at the inpatient mental health unit, prior to the nursing staff allowing Patient #4 onto the inpatient mental health unit. The nursing staff examined Patient #4's belongings, including Patient #4's jacket. The nursing staff failed to identify that Patient #4's jacket contained a cord inside the jacket. Since the nursing staff failed to identify the cord in Patient #4's jacket, the nursing staff allowed Patient #4 to bring the jacket onto the inpatient mental health unit.

Patient #4 indicated they did not want to leave the unit for dinner on 2/22/22. The nursing staff allowed Patient #4 to remain on the unit, while the other patients left the unit. While the other patients were at dinner, Patient #4 removed the cord from their jacket and tied the cord around their neck in an attempt by Patient #4 to commit suicide on the inpatient mental health unit.


6. During an interview on 4/26/22 at 1:00 PM, the Director of Risk Management and Performance Improvement (RM/PI) revealed that the hospital staff did not create any follow-up documentation or perform an investigation into the circumstances surrounding Patient #4 attempting to commit suicide in the inpatient mental health unit utilizing contraband the nursing staff failed to remove upon Patient #4's admission to the inpatient mental health unit.

The Director of RM/PI acknowledged that the hospital staff failed to create and implement a corrective plan to address the fact that nursing staff allowed Patient #4 to bring a cord from Patient #4's sweatshirt onto the inpatient mental health unit, which Patient #4 later used to attempt suicide on the inpatient mental health unit of the psychiatric hospital.

Without creating and implementing a corrective action plan after Patient #4 attempted suicide, the nursing staff could potentially allow other patients to bring contraband onto the unit, which the patients could potentially use to commit suicide.

Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to ensure that the quality assurance and performance improvement committee correctly identified that Patient #4 attempted suicide in the inpatient mental health units and then, for 60 days, failed to develop corrective actions to prevent the nursing staff from allowing patients to bring potentially lethal contraband onto the inpatient mental health units. Please refer to A-0273 for additional information.

The cumulative effect of the systemic failure and deficient practices resulted in the hospital's inability to effectively carry out the responsibilities of the hospital to ensure patients received appropriate care and treatment in a safe setting and ensure quality health care provided to patients. The Hospital's administrative staff identified a census of 36 patients at the beginning of the survey.

Based on document review and staff interview, the hospital's administrative staff failed to ensure the Quality Improvement program correctly identified patient safety issues and implemented corrective measures for 1 of 1 patient (Patient #4) who attempted suicide in the inpatient mental health units. Failure to correctly identify and implement corrective measures resulted in the hospital staff failing to prevent other patients from utilizing the same method of attempting suicide on the inpatient mental health units as Patient #4, potentially resulting in other patients successfully committing suicide on the psychiatric hospital's inpatient mental health units. The hospital's administrative staff identified a census of 36 inpatients at the start of the investigation.

Findings include:

1. Review of the Performance Improvement Plan, approved by the Governing Body 9/2021, revealed in part, "... The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care, patient safety, and organizational functions. Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether or not problems are suspected."

2. Review of the "Contraband/Search Guidelines" policy, last approved 8/2021, revealed in part, "... clothing is to be unfolded and zippers unzipped: look for belts or drawstrings ..... The discovery of contraband will be documented on a Healthcare Peer Review Occurrence Report and forwarded to the Risk Manager for review an appropriate action ...."


3. Review of Patient #4's medical record revealed:

a. The hospital staff admitted Patient #4 to the psychiatric hospital on 2/22/22 for increased depression, suicidal ideation, and psychosis.

b. Registered Nurse (RN) D completed the "Standardized Intake Assessment" form on 2/22/22 at 8:31 AM. RN D documented that when Patient #4 presented to the psychiatric hospital, Patient #4 had a razor blade in their possession, which Patient #4 gave to RN D for Patient #4's safety. Additionally, Patient #4 was hearing voices commanding Patient #4 to hurt themself, Patient #4 had a plan to kill themself by stepping in front of a car, and Patient #4's thoughts of killing themself had gotten worse while Patient #4's coping mechanisms no longer helped relieve Patient #4's thoughts of killing themself. Prior to arrival at the hospital, Patient #4 had attempted to cut their wrists, resulting in superficial cuts to Patient #4's wrists.

c. Psychiatrist E ordered the nursing staff to admit Patient #4 to the psychiatric hospital's inpatient mental health unit at 8:31 AM on 2/22/22.

d. The "Patient Belongings Inventory," which the nursing staff completed on 2/23/22 at 7:00 AM, lacked documentation the nursing staff assessed Patient #4's clothing for items Patient #4 could potentially use to harm themself, including documenting what clothes the nursing staff allowed Patient #4 to keep while on the inpatient psychiatric unit or if Patient #4's sweatshirt had a string in it.

e. On 2/22/22 at 9:45 AM, RN D documented that the nursing staff should check on Patient #4 every 15 minutes, to ensure that Patient #4 was not attempting to kill themself.



3. Review of an incident report for Patient #4, created by House Supervisor O, listed the incident type as "Fall, found on floor/Unobserved". Further review of the incident report revealed that on 2/23/22 at 5:38 PM, the nursing staff found Patient #4 laying on the floor in Patient #4's room, with Patient #4's face bright red in color. House Supervisor O found that Patient #4 had tied a jacket string tightly around Patient #4's neck. Registered Nurse (RN) J removed the jacket string from Patient #4's neck and Patient #4 resumed breathing spontaneously. Patient #4 also suffered a cut on Patient #4's forehead when Patient #4 fell to the ground after Patient #4 tied the cord around their neck in an attempt to kill themself.


4. Review of the "Nursing Standards of Practice" policy, last approved 2/2021, revealed in part, "...There is a Quality/Performance Improvement and Environment of Care Committee that meets monthly to review clinical performance (including nursing) according to valid criteria. ... Plans of action in response to findings are initiated."


5. Review of the Quality/Performance Committee Meeting minutes, dated 3/2/22, revealed " Multiple occurrences of patient suicidal behavior in January." "Events related to the use of contraband in self-injury and [suicidal attempt] events continue to be reviewed ... Focus remains on immediate removal once located as well as training ... as necessary." The follow-up on the concern was "current and ongoing monitoring."

The meeting minutes lacked evidence the quality improvement committee members reviewed or addressed the fact that Patient #4 had attempted suicide 7 days prior in the inpatient mental health unit with a contraband string the nursing staff allowed Patient #4 to bring onto the inpatient mental health unit in Patient #4's jacket. The meeting minutes lacked any documentation that the quality improvement committee members recommended any additional actions regarding Patient #4's suicide attempt except "current and ongoing monitoring."


6. During an interview on 4/26/22 at 1:00 PM, the Director of Risk Management and Performance Improvement (RM/PI) acknowledged that the nursing staff classified Patient #4's suicide attempt in the incident report as a fall. The Director of RM/PI indicated that the nursing staff had correctly classified Patient #4's suicide attempt as a fall, as Patient #4 required evaluation at Hospital A for injuries Patient #4 suffered during their suicide attempt. The Director of RM/PI acknowledged that when the quality improvement committee members reviewed the incident report summary data, Patient #4's suicide attempt would not show up, as the hospital staff categorized the suicide attempt as a fall.

The Director of RM/PI revealed that in the 60 days following Patient #4 attempting to commit suicide in the hospital's inpatient mental health unit, the hospital staff did not investigate the circumstances surrounding Patient #4's suicide attempt or attempted to identify any systemic changes necessary to prevent another patient from potentially committing suicide in the psychiatric hospital's inpatient mental health units using contraband the nursing staff allowed the patients to bring onto the inpatient mental health unit.

The Director of RM/PI verified that, because the psychiatric hospital staff had not investigated or attempted to identify necessary systemic changes, the psychiatric hospital staff failed to create and implement corrective actions, in the 60 days after Patient #4 attempted suicide, to prevent the nursing staff from allowing patients to bring contraband which the patient could use to commit suicide onto the inpatient mental health unit.


7. During an interview on 4/25/22 at 2:55 PM, the Chief Executive Officer (CEO) revealed that the psychiatric hospital staff, in the 60 days after Patient #4 attempted suicide, had not created any plans or implemented any actions to prevent other patients from bringing contraband, especially items the patients could use to commit suicide, onto the psychiatric hospital's inpatient mental health units.

Based on document review and staff interview, the psychiatric hospital's administrative staff failed to ensure the psychiatric nursing staff provided adequate nursing supervision by:

a. failing to identify and remove a cord in a patient's jacket that the patient later used to attempt to strangle themself on the inpatient mental health unit. Please refer to A-395 for additional information.

b. failing to prevent a patient with a known history of swallowing foreign objects from swallowing a marker while the patient was on the inpatient mental health unit. Please refer to A-395 for additional information.


The cumulative effect of these failures and deficient practices resulted in the psychiatric hospital's inability to provide adequate nursing supervision, which resulted in the nursing staff failing to ensure patients did not bring contraband onto the inpatient mental health unit that the patient could utilize to attempt to kill themself and ensure the patient did not obtain contraband they could swallow in an attempt to harm themself. The psychiatric hospital's administrative staff identified a census of 36 patients at the start of the investigation.

Based on document review, staff interviews, and video review, the hospital's administrative staff failed to ensure the nursing staff provided adequate nursing supervision to 2 of 2 reviewed patients (Patient #4 and Patient #5) who attempted to harm themselves on the inpatient unit and required treatment at another hospital. Failure to provide adequate nursing supervision resulted in the nursing staff failing to identify that Patient #4 had a string in their jacket and allowed Patient #4 to bring the jacket (with the string) into the inpatient mental health unit. The lack of nursing supervision resulted in Patient #4 tying the string around their neck and attempting to kill themself on the inpatient mental health unit. Failure to provide adequate nursing supervision resulted in the nursing staff allowing Patient #5 to swallow a marker on the inpatient psychiatric unit, which resulted in Patient #5 needing a hospital admission and a surgical procedure at Hospital A to remove the marker from Patient #5's stomach, and could have potentially resulted in Patient #5 dying from the marker rupturing Patient #5's internal organs. The hospital's administrative staff identified a census of 36 patients at the beginning of the survey.


Findings include:

1. Review of the "Contraband/Search Guidelines" policy, last approved 8/2021, revealed that upon admission to the inpatient mental health units, the Mental Health Technician (MHT) will search the patient's belongings. The MHT will ensure the patient's clothing has "no ties on hoodies/sweatshirts." The MHT is also required to ensure "...clothing is to be unfolded and zippers unzipped: [and] look for belts or drawstrings..."


2. Review of Patient #4's medical record revealed:

a. The hospital staff admitted Patient #4 to the psychiatric hospital on 2/22/22 for increased depression, suicidal ideation, and psychosis.

b. Registered Nurse (RN) D completed the "Standardized Intake Assessment" form on 2/22/22 at 8:31 AM. RN D documented that when Patient #4 presented to the psychiatric hospital, Patient #4 had a razor blade in their possession, which Patient #4 gave to RN D for Patient #4's safety. Additionally, Patient #4 was hearing voices commanding Patient #4 to hurt themself, Patient #4 had a plan to kill themself by stepping in front of a car, and Patient #4's thoughts of killing themself had gotten worse while Patient #4's coping mechanisms no longer helped relieve Patient #4's thoughts of killing themself. Prior to arrival at the hospital, Patient #4 had attempted to cut their wrists, resulting in superficial cuts to Patient #4's wrists.

c. Psychiatrist E ordered the nursing staff to admit Patient #4 to the psychiatric hospital's inpatient mental health unit at 8:31 AM on 2/22/22.

d. The "Patient Belongings Inventory," which the nursing staff completed on 2/23/22 at 7:00 AM, lacked documentation the nursing staff assessed Patient #4's clothing for items Patient #4 could potentially use to harm themself, including documenting what clothes the nursing staff allowed Patient #4 to keep while on the inpatient psychiatric unit or if Patient #4's sweatshirt had a string in it.

e. On 2/22/22 at 9:45 AM, RN D documented that the nursing staff should check on Patient #4 every 15 minutes, to ensure that Patient #4 was not attempting to kill themself.


3. Review of an incident report for Patient #4, created by House Supervisor O, listed the incident type as "Fall, found on floor/Unobserved". Further review of the incident report revealed that on 2/23/22 at 5:38 PM, the nursing staff found Patient #4 laying on the floor in Patient #4's room, with Patient #4's face bright red in color. House Supervisor O found that Patient #4 had tied a jacket string tightly around Patient #4's neck. Registered Nurse (RN) J removed the jacket string from Patient #4's neck and Patient #4 resumed breathing spontaneously. Patient #4 also suffered a cut on Patient #4's forehead when Patient #4 fell to the ground after Patient #4 tied the cord around their neck in an attempt to kill themself.


4. Further review of Patient #4's medical record from Hospital A revealed that the Clive Behavioral Health staff had Patient #4 taken to Hospital A following Patient #4's suicide attempt in Clive Behavioral Health. ED Physician Q documented that Patient #4 had attempted to hang themself in Clive Behavioral Health. ED Physician Q assessed Patient #4 and ordered radiologic testing to determine if Patient #4 had any internal injuries from Patient #4 attempting to strangle themself in Clive Behavioral Health. Following ED Physician Q's assessment and the radiologic testing, ED Physician Q determined Patient #4 was medically stable to return to Clive Behavioral Health.

Hospital A's Emergency Medical Services staff transported Patient #4 back to the Clive Behavioral Health. Critical Care Paramedic R documented that Patient #4 had purple bruising in the shape of a cord around Patient #4's neck and along the back of Patient #4's head. When Patient #4 attempted to commit suicide in Clive Behavioral Health, Patient #4 removed a cord from Patient #4's clothing (which the Clive Behavioral Health staff allowed Patient #4 to keep with them) and wrapped the cord around Patient #4's neck, in an attempt to commit suicide. Patient #4 lost consciousness and fell to the floor. Patient #4 struck their head on the sink while falling to the floor. Clive Behavioral Health staff found Patient #4 on the floor.


5. During an interview on 4/19/22 at 10:50 AM, RN D indicated RN D performed the admission assessment on Patient #4 when they arrived at the inpatient mental health unit, prior to the nursing staff allowing Patient #4 onto the inpatient mental health unit. The nursing staff examined Patient #4's belongings, including Patient #4's jacket. The nursing staff failed to identify that Patient #4's jacket contained a cord inside the jacket. Since the nursing staff failed to identify the cord in Patient #4's jacket, the nursing staff allowed Patient #4 to bring the jacket onto the inpatient mental health unit.

Patient #4 indicated they did not want to leave the unit for dinner on 2/22/22. The nursing staff allowed Patient #4 to remain on the unit, while the other patients left the unit. While the other patients were at dinner, Patient #4 removed the cord from their jacket and tied the cord around their neck in an attempt by Patient #4 to commit suicide on the inpatient mental health unit.


6. Review of the policy "Patient Observation Rounds/Level of Observation," approved 9/2021, revealed in part, "[Patients are] routinely observed in compliance with physician orders ..." "staff members are assigned by the Registered Nurse [on] their responsibilities in monitoring the patient ..." "staff will complete the Patient Observation Sheet as the observations are made..." "A specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times ..." "continuous observation remaining within one arm's length of the patient will continue when the patient is in shower, changing clothes or using bathroom ..."

7. Review of the policy "Patient Care Shift Assignments," approved 2/2021, revealed in part, "[A] Charge Nurse will be assigned to each nursing unit by the Nursing Supervisor." "[The] charge nurse shall plan, supervise and evaluate the nursing care of each patient ..." "[The] Nurse Manager, [and] Nursing Supervisor ... will monitor ... [patient] care demands ... [and] will make the necessary staffing adjustments for the next shift." "[D]duties and responsibilities ... [may be] delegated to other RN's [and Mental Health Technicians] ... [however, ultimate] responsibility and accountability for patient care remains with the Charge Nurse ..." "[E]xamples of tasks/duties that may be assigned [to other staff members include] ... Timed checks or constant observation (rounds, 1:1, behavior precautions) ... [and] Safety rounds/Reporting Safety issues..."



8. Review of Patient #5's medical record revealed:

a. On 3/14/22 at 5:00 AM, Psychiatrist E gave Registered Nurse (RN) J orders via telephone to admit Patient #5 from Hospital A. Psychiatrist E ordered RN J to place Patient #5 on suicide precautions and swallowing precautions (indicating that the nursing staff should closely monitor Patient #5, as Patient #5 had a history of swallowing foreign objects, such as markers, in an attempt by Patient #5 to hurt themselves).

b. At 8:50 AM, Patient #5 arrived at the psychiatric hospital's intake unit.

c. At an undocumented time, Social Worker U documented Patient #5 was transferred from Hospital A, due to Patient #5 attempting suicide and engaging in unsafe behaviors. Social Worker U documented Patient #5 had auditory hallucinations which told Patient #5 to swallow things (such as markers) and for Patient #5 to harm themself.

d. At 11:30 AM, RN T documented on the "Initial Nursing Assessment" in the "Nursing Admission Narrative Summary, "... [Patient] also states that [they] has a [history] of eating random objects - said [they] swallowed a marker but x-ray at hospital did not show anything."

e. At 12:00 PM, the psychiatric unit staff transferred Patient #5 to inpatient mental health Unit 3. Psychiatrist E again gave the nursing staff orders to place Patient #5 on suicide precautions and self-harm precautions (swallowing foreign objects was a form of self-harm). Psychiatrist E ordered the nursing staff to observe Patient #5 every 15 minutes.

f. At 2:07 PM, Physician O documented that Patient #5 was at Hospital A due to Patient #5 stating Patient #5 swallowed a marker at their group home. The ED staff at Hospital A could not identify a marker on an x-ray of Patient #5's abdomen. The ED staff at Hospital A transferred Patient #5 to Clive Behavioral Health from Hospital A, so Patient #5 could receive inpatient care for attempting to harm themself by swallowing foreign objects like a marker.

g. At 4:00 PM, Psychiatrist E ordered the nursing staff to increase Patient #5's supervision level to 1:1 observation (a staff member must continuously observe Patient #5 to prevent Patient #5 from harming themselves) due to Patient #5 informing the nursing staff that Patient #5 swallowed a marker in the hospital.

h. At 4:25 PM, Psychiatrist E documented in Patient #5's discharge summary that Patient #5 normally resided in a group home. Patient #5 informed the group home staff that Patient #5 had swallowed a marker in the group home. The group home staff had Patient #5 transferred to Hospital A, due to Patient #5 swallowing a marker. While at Hospital A, the hospital staff performed an x-ray, which did not show Patient #5 had swallowed a marker. The staff at Hospital A then transferred Patient #5 to Clive Behavioral Health for additional inpatient mental health care. While at Clive Behavioral Health, Patient #5 reported to the hospital staff that Patient #5 had swallowed a marker. The Clive Behavioral Health staff arranged to transfer Patient #5 to Hospital A for further evaluation of Patient #5 swallowing a marker.

i. Further review of Patient #5's medical record revealed that the nursing staff failed to document that Patient #5 had swallowed a marker and the Psychiatrist E had ordered the nursing staff to increase Patient #5's observation level to 1:1 (continuous) observation at 4:00 PM on 3/14/22.



9. During an interview on 4/26/22 at 1:00 PM, the Director of Risk Management and Performance Improvement (RM/PI) acknowledged that the nursing staff failed to document what time Patient #5 told the nursing staff that Patient #5 had swallowed the marker.

10. Review of Patient #5's medical record from Hospital A revealed the hospital staff admitted Patient #5 to Hospital A from 3/14/22 through 3/16/22, following Patient #5 swallowing a marker at Clive Behavioral Health. Patient #5's medical record revealed that staff at Hospital A had to remove a marker from Patient #5's stomach during a surgical procedure.

11. During an interview on 5/2/22 at 11:12 AM, Group Home Social Services Director K revealed that Patient #5 required 1:1 supervision while Patient #5 was living at the group home, prior to Patient #5 going to Hospital A on 3/13/22 after alleging that Patient #5 had swallowed a marker at the group home.

12. During an interview on 4/13/22 at 4:35 PM, MHT I revealed that the nursing administration has asked other staff members to perform 1:1 (continuous) monitoring on a patient and also perform checks every 15 minutes on other patients while the staff member is assigned to provide 1:1 monitoring, due to staffing issues.

13. During an interview on 4/14/22 at 11:35 AM, MHT M revealed that the nursing units sometimes lacked adequate staffing, resulting in the nursing staff's inability to provide 1:1 observation. Sometimes, if a patient required 1:1 observation, and the hospital lacked sufficient nursing staff to provide 1:1 observation to the patient, the nursing staff would not place the patient on 1:1 observation, since the nursing staff did not have a staff member available to provide continuous 1:1 monitoring for the patient.

I. Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to ensure the nursing staff developed a nursing care plan for 1 of 1 reviewed patient (Patient #1). Failure to create a nursing care plan could potentially have resulted in Patient #1 committing an act of self-harm on 4/1/22 and then committing a second act of self-harm on 4/6/22, which required Patient #1 to receive treatment in the Emergency Department (ED). The hospital's administrative staff identified a census of 36 patients at the start of the investigation.

Findings include:

1. Review of the policy "Plan for the Provision of Nursing Care", last revised 12/2021, revealed in part, "Nursing care needs of patients shall be identified using the nursing process. Specifically, registered nurses shall use assessment skills initially and on an on-going basis to determine the level of care and necessary interventions to ensure that the identified needs are addressed. The appropriateness of interventions will be evaluated for effectiveness with targeted positive patient outcomes as the criteria. Modifications shall be made in the treatment strategies based on the nurses's evaluation of the patient's response to interventions..."

2. Review of the policy "Nursing Standards of Practice", last revised 02/2021, revealed in part, "On admission, the nurse initiates the collection of data concerning the health status and emotional state of the person ... Problem lists are derived from admission data and are formulated in the nursing care plan ... Nursing actions are consistent with the care plans ... The individuals progress or lack of progress toward goal achievement directs reassessment ... new goal setting, and revision of the nursing care plan ..."


2. Review of Patient #1's medical record revealed:

a. On 3/25/22, the hospital staff admitted Patient #1 to the psychiatric hospital. Patient #1 had a history of multiple hospitalizations, drug overdoses, and self-harm.

b. On 4/1/22 at approximately 1:40 PM, Patient #1 used a paper clip to scratch their arms. Patient #1 had superficial scratches. The nursing staff cleaned the scratches and applied bandages to Patient #1's arms.

c. On 4/6/22 at approximately 9:10 PM, Patient #1 used a tape dispenser to cut their arms. The hospital staff transferred Patient #1 to the ED for treatment of the cuts from the tape dispenser. Patient #1 returned to the psychiatric hospital on 4/7/22 at approximately 1:00 AM.

d. Patient #1's medical record lacked evidence of a nursing care plan, which would have included any documentation of problems the nursing staff identified for Patient #1 to work on during the hospitalization and interventions the nursing staff implemented to keep Patient #1 safe during the hospitalization, especially after Patient #1 attempted to harm themself by scratching their arms with a paperclip.


3. During an interview on 4/14/22 at 4:15 PM, the Clinical Director confirmed that Patient #1's medical record lacked a nursing care plan.




II. Based on document review and staff interview, the psychiatric hospital's administrative staff failed to ensure that the nursing staff updated the Master Treatment Plan for 1 of 1 patient (Patient #1) reviewed. Failure to ensure that the nursing staff updated the Master Treatment Plan could potentially have resulted in Patient #1 committing an act of self-harm on 4/1/22 and then committing a second act of self-harm on 4/6/22, which required Patient #1 to receive treatment in the Emergency Department (ED). The hospital's administrative staff identified a census of 36 patients at the beginning of the investigation.

Findings include:

1. Review of the policy "Interdisciplinary Patient Centered Care Planning", last revised 11/2020, revealed in part, "Treatment Plan Review: The treatment team ... will complete a review of the treatment plan as clinically indicated ... The following would be cause for conducting a review and developing a revision: ... A new impairment/problem or significant information about an existing impairment is identified ..."

2. Review of Patient #1's medical record revealed:

a. On 3/25/22, the hospital staff admitted Patient #1 to the psychiatric hospital. Patient #1 had a history of multiple hospitalizations, drug overdoses, and self-harm.

b. On 4/1/22 at approximately 1:40 PM, Patient #1 used a paper clip to scratch their arms. Patient #1 had superficial scratches. The nursing staff cleaned the scratches and applied bandages to Patient #1's arms.

c. On 4/6/22 at approximately 9:10 PM, Patient #1 used a tape dispenser to cut their arms. The hospital staff transferred Patient #1 to the ED for treatment of the cuts from the tape dispenser. Patient #1 returned to the psychiatric hospital on 4/7/22 at approximately 1:00 AM.

d. Review of the Master Treatment Plan in Patient #1's medical record revealed that the hospital staff added "Panic Attacks" to Patient #1's Master Problem List on 3/25/22 (the date of Patient #1's admission to the hospital). The Master Treatment Plan lacked any additional updates during Patient #1's hospitalization. The Master Treatment Plan specifically lacked any changes following Patient #1's attempt to harm themself on either 4/1/22 or 4/6/22.


3. During an interview on 4/14/22 at 4:15 PM, the Clinical Director confirmed that the hospital staff did not update Patient #1's interdisciplinary Master Treatment Plan to reflect all of Patient #1's problems during the hospitalization. The Clinical Director explained that the hospital staff should have added "self-harm" to Patient #1's problem list after Patient #1 scratched their arms with a paper clip on 4/1/22 and the hospital staff should have revised Patient #1's Master Treatment Plan to reflect Patient #1's self-harm from the paperclip. The Clinical Director further explained that the hospital staff again should have updated Patient #1's Master Treatment Plan to reflect "self-harm" following Patient #1 cutting their arms with the tape dispenser.

Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to follow their policy and test 2 of 3 patients reviewed (Patient #2 and Patient #3) for COVID -19 prior to admission to the psychiatric hospital. Failure to test patients for COVID-19 prior to admission to the hospital could potentially result in the hospital staff admitting a patient who was positive for COVID-19, but was asymptomatic, and potentially result in the infected patient spreading COVID-19 to another patient, potentially resulting in the second patient developing life-threatening COVID-19, potentially resulting in the second patient's death.

Findings include:

1. Review of the policy "Screening Policy Covid -19, last revised 06/2021, revealed in part, "All Patients admitted to the [psychiatric hospital] will be tested for Covid-19 in the Intake department and before they are brought to the inpatient unit."

2. Review of medical records revealed:

a. On 2/24/22 at 9:00 PM, the hospital staff admitted Patient #2 to the psychiatric hospital. Patient #2's medical record lacked evidence the hospital staff had tested Patient #2 for COVID-19 prior to admitting Patient #2 to an inpatient mental heath unit.

b. On 3/22/22 at 9:52 PM, the hospital staff admitted Patient #3 to the psychiatric hospital. Patient #3's medical record lacked evidence the hospital staff had tested Patient #3 for COVID-19 prior to admitting Patient #3 to an inpatient mental heath unit.


3. During an interview on 4/18/22 at 9:00 AM, the Chief Medical Officer (CMO) explained that the hospital staff ask every patient screening questions for COVID-19 prior to admitting the patient to an inpatient mental health unit. Unless the patient had COVID-19 symptoms at the time of the patient's admission to the hospital, the hospital staff did not test the patient for COVID-19. The CMO acknowledged the process would fail to identify a patient with an asymptomatic COVID-19 infection, which could allow the asymptomatic patient to spread COVID-19 to another patient in the inpatient mental health units. The CMO confirmed that the hospital staff did not test every patient admitted onto the inpatient mental health units, but instead only tested patients for COVID-19 if the patient displayed symptoms of COVID-19. The CMO acknowledged that the hospital's policy required the hospital staff to test every patient admitted to the inpatient mental health units for COVID-19, regardless if the patient displayed symptoms of COVID-19.