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Based on observations, interview and record review, the facility failed to provide a safe enviroment for one (P-1) of fifteen (15) patients reviewed for patient's rights, resulting in the death of P-1, and the potential for further incidents to occur with all patients. Findings include:

See A-0144 - Failure to provide care in a safe setting.

Based on interview, observation and record review, the facility failed to ensure a safe environment for one (P-1) of fifteen patients reviewed for patient rights, resulting in the death of P-1, and potentially resulting in the loss of patient rights for all 220 patients being served at the facility. Findings include:

Review of document "History of Present Illness," dated 06/12/24 revealed that P-1 was a 21-year-old female with a history of bipolar disorder, attention-deficit hyper-activity disorder (ADHD) and traumatic brain injury (TBI). P-1 was admitted to a local psychiatric hospital in April of 2024 and was discharged to home on long-acting forms of Haldol (anti-psychotic medication) and Abilify (antipsychotic medication). P-1 reported symptoms of medication side-effects and was placed on cogentin. She presented to the facility of concern on 06/11/24 after being found unresponsive in a vehicle on the freeway. Police noted an empty bottle of Cogentin on P-1's lap when she was found, with approximately 75 pills unaccounted for.

This record review also revealed that P-1 was transported to the facility's Emergency Department, where she was intubated (breathing tube placed). P-1 was admitted to the facility's medical intensive care unit (MICU) on 06/11/24. Following extubation (breathing tube removed) on 06/13/24, she stated that she took 75 pills in an attempt to "get some sleep." P-1 was assessed by psychiatry and placed in 1:1 close observation while in the MICU. P-1's recovery from the overdose was expected to take 7-8 days. P-1 was transferred to a general medical unit on 06/15/24, where she remained on 1:1 close observation. Once medically cleared, she was transferred to the facility's psychiatric unit (3Q) on 06/19/24. P-1's physician ordered safety precautions of "every 15-minute safety observations." On 06/22/24 at 1704, P-1 was found unresponsive, hanging from the bathroom door, with bed linens wrapped around her neck.

A tour of the behavioral unit 3Q, room 10A-10B, was conducted at approximately 1140 on 07/02/24 with ACNO Staff S. Observations of the room demonstrated that the bathroom door was not square at its top edge, as the room entry door was. During this tour, an interview was conducted with ACNO Staff S. Staff S was questioned why the top of the bathroom doors were angled. Staff S stated that the top of the bathroom door was anti-ligature (designed to prevent hanging/suicide). Staff S stated, "She was able to fix the ligature between the bathroom door and the door frame, at the non-hinged side." Staff S also stated that she herself attempted to replicate P-1's actions by attempting to secure a similar (bed sheet) ligature at the door and frame junction. Staff S stated that she too was able to secure the ligature and it was able to support her full weight.

Review of document titled "15-minute Safety Check Rounding" dated 06/22/24 revealed that Mental Health Tech (MHT) Staff Y did not document safety checks as ordered, after 1630 on 06/22/24.

An interview was conducted with CNO Staff B and ACNO Staff S at 1353 on 07/02/24. Staff S stated that video review confirmed that MHT Staff Y did not do safety checks after 1630 on 06/22/24. Staff S stated that P-1 was discovered after her roommate approached the nursing station.