HospitalInspections.org

Based on a review of medical records (MR), a review of facility documents and interview with staff it was determined the facility failed to provide adequate supervision to maintain a patient's safety resulting in the patient's suicide (patient #1) for one (1) out of ten (10) medical records reviewed. As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 7/2/21 at 4:28 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 7/2/21 at 11:27 p.m. (See Tag A 144).

The following interventions were implemented to resolve the IJ:

On 7/2/21, the hospital revised the "Patient Monitoring" policy to ensure the Registered Nurse (RN) reports to the provider any active or recent suicide attempts by the patient, and patients who have made a suicide attempt in the past thirty (30) days will be placed on one to one (1:1) monitoring for a minimum of twenty-four (24) hours and the provider may decrease the monitoring to every five (5) minutes if their face-to-face assessment determines the patient does not require continued 1:1 monitoring.

The RN will not engage in a "commitment to safety" contract with any patient. On 7/2/21, the Interim Chief Nursing Officer (ICNO) and the House Supervisors will educate staff currently working before the end of their shift and other staff before they begin their shift on the above policy changes.

On 7/2/21, the revisions to the "Patient Monitoring" policy will be communicated to the providers by the Interim Chief Executive Officer (ICEO) by email and the ICEO will acknowledge receipt of the new policy by return email.

The ICNO educated the Nurse Supervisors on the proper completion of the Suicide Risk Assessment (SRA).

On 7/2/21, all RNs working the evening shift had been re-trained by the House Supervisor. Re-training will begin for the other RNs prior to the beginning of their next shift.

On 7/3/21, one hundred (100) percent of the SRA's will be audited daily for thirty (30) days. After thirty (30) days one hundred (100) percent will be audited one (1) day per week. The threshold will be one hundred (100) percent.

Deficiencies will be immediately corrected by the ICNO and House Supervisors. The RN staff will immediately be re-trained by the ICNO or House Supervisor.

On 7/3/21, all acute patients will be reassessed using the Columbia Suicide Severity Rating Scale (CSSR)/SRA by the House Supervisors under the oversight of the ICNO. Once the patients are re-assessed the results will be communicated to the staff by the ICNO and/or the House Supervisor.

Based on review of facility documents, medical record (MR) and video, and interview with staff it was determined the facility failed to provide adequate supervision to maintain a patient's safety resulting in a patient's suicide (patient #1) for one (1) of twenty-five (25) medical records reviewed. The failure to adequately supervise has the potential to adversely affect all patents in the facility.

Findings include:

A review of the hospital policy entitled "Patient Monitoring," last revised 10/20, revealed in part: "... Level Red Only - Must be assigned to a staff member providing 1:1 supervision at all times for personal hygiene, toileting, and other self-care needs ... 1:1 supervision is defined as: a. within arms' reach of the assigned staff member and never out of visual contact ..."

A review of the document entitled "Columbia-Suicide Severity Rating Scale Screen Version-Recent," copyright 2008, revealed in part: "Low Risk-Yellow, Moderate Risk-Orange, High Risk- Red ... Ask questions 1 and 2 ... Past Month: 1) Have you wished you were dead or could not wake up? Yes-Yellow ... 2) Have you actually had any thoughts of killing yourself? Yes-Yellow ... If ' YES' to 2, ask questions 3, 4, 5 and 6 ... 3) Have you been thinking about how you might do this? Yes-Orange ... 4) Have you had these thoughts and had some intention on acting on them? Yes-Red..."

A review of the hospital policy entitled "Suicide Risk Assessment Guidelines," revised 5/19, revealed in part: "Procedure: The Columbia Suicide Severity Rating Scale (C-SSRS) (Lifetime-Recent) Screen Version will be used to identify suicide risk, and will be completed on admission to the hospital ... Presence of ANY suicidal behavior ... in the past 3 months indicates a severe risk and clear need for further evaluation ... A score of low, moderate or high on the CSSR Screen Version (Lifetime-Recent) mandates contact with the provider if the score is high ..." "...A moderate score on the CSSR screen version triggers specific interventions. A moderate score triggers15 minute observations, daily reassessment utilizing CSSR (since last contact) and the selection of the following interventions based on patient's need and presentation: Daily Room Search for Contraband, Patient Room Close to RN Station, 5 minute observations (must have doctor order). The clinical team, which includes the provider, will select any of the above as appropriate interventions. If a patient scores moderate and is only placed on 15 minute observations, justification must be documented ..." "... A high score on the CSSR screen version triggers specific interventions. A high score triggers 15 minute observations, daily reassessment utilizing CSSR (Since Last Contact) and the selection of the following interventions based on patients need and presentation: 1-1 Observation (must have doctor order), Daily Room Search for Contraband, Patient Room Close to RN Station, 5 minute observations (must have doctor order). The clinical team, which includes the provider, will select any of the above as appropriate interventions. If a patient scores high and is not placed on 1-1 observations, justification must be documented ..."

A review of the medical record for patient #1 revealed the patient had been admitted to the hospital on 6/24/21 for treatment due to previous suicide attempts. Further review of patient #1's medical record revealed that prior to admission to the facility the patient attempted to cut their wrist and jump from a moving truck; within the last two (2) months the patient overdosed on prescription medications.

A review of the medical record for patient #1 revealed the patient answered "Yes" to 1) "Have you wished you were dead or could not wake up?", 2) "Have you actually had any thoughts of killing yourself?", 3) "Have you been thinking about how you might do this?" and 4) "Have you had these thoughts and had some intention of acting on them?" on the C-SSRS. The "Risk Assessment" narrative revealed in part: "Patient Assigned Risk: Moderate Risk (Yellow). Moderate Risk: Monitor Q 15 minutes and document."

A review of the nursing notes in the medical record for patient #1 revealed that on 6/25/21 at 12:06 a.m. the patient was found unresponsive by Behavioral Health Technician (BHT) #4. BHT #4 notified RN #3. RN #3 entered the room and turned the patient over. The patient was found with a sock in their mouth and another sock towards the back of their throat. RN #3 also found toilet tissue in the patient's nostrils. RN #3 removed the socks and toilet tissue and initiated Cardiopulmonary Resuscitation (CPR) until Emergency Medical Services (EMS) arrived. The patient was transferred to an acute care hospital where they were pronounced expired.

A review of video footage showed the patient walking out of their room at 11:31 p.m. and into the bathroom. At 11:32 p.m., the patient was observed walking out of their bathroom carrying something white in their left hand.

A telephone interview with RN #1 on 6/30/21 at approximately 1:45 p.m. revealed RN #1 had completed the patient's suicide risk assessment (C-SSRS). RN #1 said patient #1 denied suicidal ideation at that time. RN #1 stated, "Upon entering the facility [the patient] denied being suicidal and committed to safety." RN #1 said because the patient had a recent attempt of wrist cutting, RN #1 made the patient a moderate risk. RN #1 stated this had been discussed with the physician when the patient was in admissions.

An interview was conducted with the Interim Chief Nursing Officer (ICNO) on 7/2/21 at approximately 2:50 p.m. and the ICNO agreed patient #1 should have been assigned a red - high risk on the C-SSRS and the RN should have discussed this with the physician after completing the suicide risk assessment.

Based on document review, medical record review and interview it was revealed the hospital failed to ensure nursing services correctly evaluated and supervised a patient with a recent suicide attempt (patient #1) for one (1) of twenty-five (25) medical records reviewed. The failure to correctly evaluate and supervise suicidal patients has the potential to affect all patients who have had a recent suicide attempt.

Findings include:

A review of the hospital policy entitled "Patient Monitoring," last revised 10/20, revealed in part: "Upon admission, the RN will assess all patients for the presence of suicidal ideation and/or risk of suicide ... The admitting RN discusses the patient's level of suicide risk with the physician to determine the precautions that are indicated ..."

A review of the hospital policy entitled "Suicide Risk Assessment Guidelines," revised 5/19, revealed in part: "Procedure: The Columbia Suicide Severity Rating Scale (C-SSRS) (Lifetime-Recent) Screen Version will be used to identify suicide risk, and will be completed on admission to the hospital ... Presence of ANY suicidal behavior ... in the past 3 months indicates a severe risk and clear need for further evaluation ..."

A review of the medical record for patient #1 revealed the patient answered "Yes" to the following questions on the C-SSRS Screen Version: 1) "Have you wished you were dead or could not wake up?" (which is assigned a low level of risk (yellow) on the form) , 2) "Have you actually had any thoughts of killing yourself?" (which is assigned a low level of risk (yellow) on the form), 3) "Have you been thinking about how you might do this?" (which is assigned a moderate level of risk (orange) on the form), and 4) "Have you had these thoughts and had some intention of acting on them?" (which is assigned a high level of risk (red) on the form). The "Risk Assessment" narrative revealed in part: "Patient Assigned Risk: Moderate Risk (Yellow). Moderate Risk: Monitor Q 15 minutes and document" when the patient had answered yes to question #4 which placed the patient in the high risk category.

A telephone interview with Registered Nurse (RN) #1 on 6/30/21 at approximately 1:45 p.m. revealed she had completed the patient's suicide risk assessment. She said patient #1 denied suicidal ideation at that time. RN #1 stated, "Upon entering the facility [the patient] denied being suicidal and committed to safety." RN #1 said because the patient had a recent attempt of cutting the wrists, RN #1 made the patient a moderate risk. RN #1 stated they had discussed this with the physician when the patient was in admissions. RN #1 did not notify the physician of the C-SSRS results.

An interview was conducted with the Interim Chief Nursing Officer (ICNO) on 7/2/21 at approximately 2:50 p.m. and the ICNO agreed patient #1 should have been assigned a red - high risk based on the results of the C-SSRS and the RN should have discussed the results with the physician after completing the suicide risk assessment.