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Based on clinical record review, review of Hospital documentation, review of policies, and interviews with staff for 19 patients (Patients #2 through 20) who were admitted to the psychiatry unit, the Hospital failed to ensure that care was delivered in a safe setting when the environment was identified as unsafe (presence of side rails on beds) and staff failed to assess/reassess each patient's environmental safety needs. Please refer to A143, A144, and A275.

Based on a review of clinical records, interviews with staff, observation, and review of policies for 2 patients (Patients #7 and #17), the hospital failed to ensure that the patient's privacy was maintained and that care and services were provided in a dignified manner. The findings include:

1. Patient #7 was admitted on 7/29/10 with a diagnosis of mood disorder and had recently attempted suicide, sustaining a gun shot wound. The treatment plan identified mood disorder, and suicidal ideations with an intervention to maintain a safe environment. An observation on 8/9/10 at 9:25 AM identified that an outside Clinical Social Worker was conducting an assessment of Patient #7 in the lounge area that was open to the milieu with other patients present. Patient #7 was over heard saying "wait, let me get closer to you." "I don't want anyone to hear." Upon surveyor inquiry, the patient and Social Worker were directed to a private area.

2. Patient #17 was admitted on 8/10/10 with diagnoses of mood and borderline personality disorders and identified as clinically suicidal. The treatment plan identified a mood disorder, poor impulse control, and suicidal ideations with an intervention to maintain a safe environment by placing the patient on lounge restriction for safety. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10 who identified that Patient #17 was found with a knife hidden in his/her bedroom and was subsequently placed on 24 hour lounge restriction for safety. The patient's mattress was brought to the lounge each night to provide a place to sleep. The lounge was observed on 8/9/10 and noted to be an open area for the general population use and provided no privacy for a patient sleeping on a mattress in that area. The treatment plan failed to identify an appropriate environment that would be safe for Patient #17 while maintaining personal privacy and dignity.

Based on a review of clinical records, review of Hospital documentation, review of policies, and interviews with staff for 1 patient (Patient #1) who was admitted to the psychiatry unit with suicidal ideations, the Hospital failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess the patient's environmental safety needs (presence of side rails on beds).
In addition, for 19 of 19 patients (Patients #2 through 20) who were receiving treatment in the psychiatry unit, the Hospital failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess each patient's environmental safety needs when the environment was identified as potentially unsafe (presence of side rails on beds on 8/4/10) The findings include:

1. Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates. The patient was assessed by MD #1 (Psychiatrist) on 8/3/10 and identified with diagnoses of severe major depressive disorder, opiate dependency, borderline personality disorder and was a suicide risk. The treatment plan identified suicidal ideations/gesture due to the patient's attempt to kill his/her self and mood disorder. Interventions included to maintain a safe environment and assess suicidality daily and as needed. The plan failed to identify the type of environment that would be safe for Patient #1, and failed to identify who would assess suicidality, when suicidality would be assessed, what would be done based on that assessment, and how it would be documented and communicated to others. The patient was assessed by a psychiatric APRN on 8/3/10, identified as experiencing opiate withdrawal, and had positive suicidal ideations. The APRN identified a plan to medicate for the opiate withdrawal symptoms and to offer emotional support. On 8/4/10 at 12 PM the APRN identified that the patient had vague suicidal ideations and continued to experience opiate withdrawal symptoms. The plan was to continue to medicate for the opiate withdrawal symptoms, offer emotional support, and start discharge planning. On 8/4/10 at 12:27 PM, RN #1 identified that Patient #1 had positive suicidal ideations, was isolative, depressed, felt that he/she had nothing, did not feel well, and reported that he/she would like to die. RN #1 identified to monitor the patient's mood and behavior. However, the clinical record failed to identify that RN #1 further assessed the patient's suicidality, and failed to ascertain if the patient would contract for safety and seek staff if he/she did not feel safe. Patient #1 was on 15-minute checks and was last observed at 5:30 PM. Approximately 10 minutes later, Patient #2 (Patient #1's room mate) identified that someone needed to check Patient #1. Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. The patient was cut down and noted to be unresponsive and pulseless. CPR was administered, a pulse was reestablished, and the patient was intubated. Patient #1 was treated in the ICU, experienced seizures, and had pupils that were fixed and dilated. On 8/7/10 at 1:43 PM with family at the bedside, Patient #1 was extubated and expired at 1:59 PM.

2. Tour of the psychiatric unit on 8/9/10 identified 19 of 19 adult patients (Patients #2 through 20) currently under treatment and occupying beds with side rails. Interview with the Nurse Administrator on 8/9/10 at 9:15 AM identified that suicide risk assessments are conducted for all patients on admission and every shift. Prior to 8/4/10, the risk assessments did not include the risk posed by the presence of side rails on beds. However, once the side rails were known to pose a safety risk (8/4/10), staff failed to reassess patients for this risk. Following surveyor inquiry on 8/9/10, MD's #1 and #2 conducted side rail safety assessments on all patients.

Based on a review of clinical records, review of policies, interview with staff, and review of Hospital documentation for 13 of 27 patients (Patients #3, #6, #7, #8, #9, #11, #12, #13, #14, #16, #18, #19 and #21) who resided on the psychiatric unit, the Hospital failed to immediately collect data in order to monitor the effectiveness and safety of care and services provided to patients in the presence of side rails once known that side rails posed a risk for hanging, necessitating an immediate action plan on 8/9/10. The findings include:

1. Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates and placed on 15-minute checks. On 8/4/10 Patient #1 was last observed at 5:30 PM. Approximately 10 minutes later, Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. The patient was cut down and noted to be unresponsive and pulseless. CPR was administered, a pulse was reestablished, and the patient was intubated. Patient #1 was treated in the ICU, experienced seizures, and had pupils that were fixed and dilated. On 8/7/10 at 1:43 PM with family at the bedside, Patient #1 was extubated and expired at 1:59 PM. Subsequent to Patient #1's hanging on 8/4/10, the following was ascertained:

2. Patient #3 was admitted on 8/4/10 with diagnoses of schizophrenia and psychosis, impaired judgment and a positive history of violence. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to evaluate the patient's safety in the presence of side rails, once known that side rails posed a risk for hanging.

3. Patient #6 was admitted on 8/8/10 with diagnoses of depression and mood disorder and had recent suicidal and homicidal ideations. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/8/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

4. Patient #7 was admitted on 7/29/10 with a diagnosis of mood disorder and had recently attempted suicide, sustaining a gun shot wound. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

5. Patient #8 was admitted on 8/5/10 with a diagnosis of mood disorder and had recently intentionally cut self with a piece of glass in an attempt to harm his/her self. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/5/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

6. Patient #9 was admitted on 8/4/10 with a diagnosis of mood disorder and had recently attempted suicide by consuming an overdose of medication. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

7. Patient #11 was admitted on 7/27/10 with a diagnosis of schizophrenia. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

8. Patient #12 was admitted on 8/4/10 with diagnoses of schizoaffective disorder and dementia. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

9. Patient #13 was admitted on 8/6/10 with diagnoses of bipolar and oppositional defiant disorders, and behavioral dyscontrol. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/6/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

10. Patient #14 was admitted on 8/7/10 with a diagnosis of bipolar disorder, and manic with psychotic features. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/7/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

11. Patient #16 was admitted on 8/3/10 with diagnoses of schizoaffective disorder, borderline personality, with recent self inflicted lacerations requiring 15 staples and 8 sutures. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

12. Patient #18 was admitted on 7/14/10 with diagnoses of schizoaffective and borderline personality disorders, with multiple serious overdose attempts. The Clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

13. Patient #19 was admitted on 8/3/10 with a diagnosis of major depression, severe with psychotic features, with a recent attempt to cut self with a knife. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

14. Patient #21 was admitted on 8/3/10 with diagnoses of psychosis and personality disorder of the criminal type, with recent suicidal thoughts. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

Based on clinical record review, review of Hospital documentation, review of policies, and interviews with staff for 1 patient (Patient #1) who was admitted to the psychiatry unit with suicidal ideations, the Medical Staff failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess the patient's environmental safety needs (presence of side rails on beds). Please refer to A347.

Based on clinical record review, review of Hospital documentation, review of policies, and interviews with staff for 1 patient (Patient #1) who was admitted to the psychiatry unit with positive suicidal ideations, the Hospital failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess the patient's environmental safety needs (presence of side rails on beds). The findings include:

Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates. The patient was assessed by MD #1 (Psychiatrist) on 8/3/10 and identified with diagnoses of severe major depressive disorder, opiate dependency, borderline personality disorder and was a suicide risk. The treatment plan identified suicidal ideations/gesture due to the patient's attempt to kill his/her self and mood disorder. Interventions included to maintain a safe environment and assess suicidality daily and as needed. The plan failed to identify the type of environment that would be safe for Patient #1, and failed to identify who would assess suicidality, when suicidality would be assessed, what would be done based on that assessment, and how it would be documented and communicate to others. The patient was assessed by a psychiatric APRN on 8/3/10, identified as experiencing opiate withdrawal, and had positive suicidal ideations. The APRN identified a plan to medicate for the opiate withdrawal symptoms and to offer emotional support. On 8/4/10 at 12 PM the APRN identified that the patient had vague suicidal ideations and continued to experience opiate withdrawal symptoms. The plan was to continue to medicate for the opiate withdrawal symptoms, offer emotional support, and start discharge planning. However, the patient's continued suicidal ideations were not addressed at that time. On 8/4/10 at 12:27 PM, RN #1 identified that Patient #1 had positive suicidal ideations, was isolative, depressed, felt that he/she had nothing, did not feel well, and reported that he/she would like to die. RN #1 identified to monitor the patient's mood and behavior. However, the clinical record failed to identify that RN #1 further assessed the patient's suicidality, and failed to ascertain if the patient would contract for safety and seek staff if he/she did not feel safe. Patient #1 was placed on 15-minute checks and was last observed at 5:30 PM. Approximately 10 minutes later, Patient #2 (Patient #1's room mate) identified that someone needed to check Patient #1. Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. The patient was cut down and noted to be unresponsive and pulseless. CPR was administered, a pulse was reestablished, and the patient was intubated. Patient #1 was treated in the ICU, experienced seizures, and had pupils that were fixed and dilated. On 8/7/10 at 1:43 PM with family at the bedside, Patient #1 was extubated and expired at 1:59 PM.

Following surveyor inquiry on 8/9/10, MD's #1 and #2 conducted side rail safety assessments on all patients.

Based on clinical record review, review of Hospital documentation, review of policies, and interviews with staff for 1 patient (Patient #1) who was admitted to the psychiatry unit with positive suicidal ideations, Nursing staff failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess and care plan for the patient's environmental safety needs (presence of side rails on beds), and failure to provide sufficient numbers of staff, based on the needs and/or acquity of patients. Please refer to A392, A395 and A396.

Based on review of Hospital documentation, review of staffing, and interviews with staff, the Hospital failed to ensure that there were sufficient numbers of staff on the psychiatric unit, based on the Hospital's staffing guide. The findings include:

Review of the staffing guidelines for the psychiatric unit identified that staffing was based on an average census of 19, despite the unit capacity of 30 patients. The staffing pattern for 19 patients identified the need for 4 RN's, 2 Psychiatric Technicians, and 1 Patient Care Assistant. Interview with the Director of Acute Care Behavioral Health Services on 8/17/10 at 3 PM identified that the unit's staffing guidelines did not reflect staffing requirements or guidelines if the patient census rose above 19, but that if the census or acuity was high, the staffing level would increase. The Director of Acute Care Behavioral Health Services identified that there was no system in place to measure patient acuity. Review of staffing and patient census from 7/18/10 to 8/4/10 identified that the patient census rose above 19 on 10 days, and that staffing was not increased accordingly on 8 of the 10 days, and/or lacked rationale for not adding additional staff.

Based on a review of clinical records, review of Hospital documentation, review of policies, and interviews with staff for one patient (Patient #1) who was admitted to the psychiatric unit with positive suicidal ideations, nursing staff failed to ensure that care was delivered in a safe setting when staff failed to assess/reassess the patient's environmental safety needs (presence of side rails on beds).

In addition, for 13 of 27 patients (Patients #3, #6, #7, #8, #9, #11, #12, #13, #14, #16, #18, #19 and #21) nursing staff failed to perform an assessment of each patients safety in the presence of side rails once known that side rails posed a risk for hanging.

In addition, for 10 patients (Patients #2, #4, #9, #10, #11, #17, #18, #19, #24 and #27), nursing staff failed to include an assessment for side rails in the environmental risk assessment conducted each shift, as identified in an immediate action plan developed on 8/9/10. The findings include:

1. Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates. The patient was assessed by MD #1 (Psychiatrist) on 8/3/10 and identified with diagnoses of severe major depressive disorder, opiate dependency, borderline personality disorder and was a suicide risk. The treatment plan identified suicidal ideations/gesture due to the patient's attempt to kill his/her self and mood disorder. Interventions included to maintain a safe environment and assess suicidality daily and as needed. The plan failed to identify the type of environment that would be safe for Patient #1, and failed to identify who would assess suicidality, when suicidality would be assessed, what would be done based on that assessment, and how it would be documented and communicate to others. The patient was assessed by a psychiatric APRN on 8/3/10, identified as experiencing opiate withdrawal, and had positive suicidal ideations. The APRN identified a plan to medicate for the opiate withdrawal symptoms and to offer emotional support. On 8/4/10 at 12 PM the APRN identified that the patient had vague suicidal ideations and continued to experience opiate withdrawal symptoms. The plan was to continue to medicate for the opiate withdrawal symptoms, offer emotional support, and start discharge planning. On 8/4/10 at 12:27 PM, RN #1 identified that Patient #1 had positive suicidal ideations, was isolative, depressed, felt that he/she had nothing, did not feel well, and reported that he/she would like to die. RN #1 identified to monitor the patient's mood and behavior. However, the clinical record failed to identify that RN #1 further assessed the patient's suicidality, and failed to ascertain if the patient would contract for safety and seek staff if he/she did not feel safe. Patient #1 was placed on 15-minute checks and was last observed at 5:30 PM. Approximately 10 minutes later, Patient #2 (Patient #1's room mate) identified that someone needed to check Patient #1. Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. The patient was cut down and noted to be unresponsive and pulseless. CPR was administered, a pulse was reestablished, and the patient was intubated. Patient #1 was treated in the ICU, experienced seizures, and had pupils that were fixed and dilated. On 8/7/10 at 1:43 PM with family at the bedside, Patient #1 was extubated and expired at 1:59 PM.

2. Patient #3 was admitted on 8/4/10 with diagnoses of schizophrenia and psychosis, impaired judgment and a positive history of violence. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to evaluate the patient's safety in the presence of side rails, once known that side rails posed a risk for hanging.

3. Patient #6 was admitted on 8/8/10 with diagnoses of depression and mood disorder and had recent suicidal and homicidal ideations. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/8/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

4. Patient #7 was admitted on 7/29/10 with a diagnosis of mood disorder and had recently attempted suicide, sustaining a gunshot wound. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

5. Patient #8 was admitted on 8/5/10 with a diagnosis of mood disorder and had recently intentionally cut self with a piece of glass in an attempt to harm his/her self. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/5/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

6. Patient #9 was admitted on 8/4/10 with a diagnosis of mood disorder and had recently attempted suicide by consuming an overdose of medication. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

7. Patient #11 was admitted on 7/27/10 with a diagnosis of schizophrenia. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

8. Patient #12 was admitted on 8/4/10 with diagnoses of schizoaffective disorder and dementia. The clinical record was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

9. Patient #13 was admitted on 8/6/10 with diagnoses of bipolar and oppositional defiant disorders, and behavioral dyscontrol. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/6/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

10. Patient #14 was admitted on 8/7/10 with a diagnosis of bipolar disorder, and manic with psychotic features. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/7/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

11. Patient #16 was admitted on 8/3/10 with diagnoses of schizoaffective disorder, borderline personality, with recent self inflicted lacerations requiring 15 staples and 8 sutures. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

12. Patient #18 was admitted on 7/14/10 with diagnoses of schizoaffective and borderline personality disorders, with multiple serious overdose attempts. The Clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

13. Patient #19 was admitted on 8/3/10 with a diagnosis of major depression, severe with psychotic features, with a recent attempt to cut self with a knife. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

14. Patient #21 was admitted on 8/3/10 with diagnoses of psychosis and personality disorder of the criminal type, with recent suicidal thoughts. The clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

15. On 8/9/10 the Hospital developed an immediate action plan to address safety issues on the psychiatric unit. The plan identified that nursing staff would include side rails in their environmental risk assessment and document this each shift in a progress note. The clinical records of Patients #2, #4, #9, #10, #11, #17, #18, #19, #24 and #27 were reviewed with the Assistant Nursing Director on 8/12/10. Nursing staff failed to perform an assessment for side rails in the environmental risk assessment conducted each shift (as identified in an immediate action plan developed on 8/9/10) on one or more shifts between 8/9/10 and 8/12/10.

Based on a review of clinical records, review of Hospital documentation, review of policies, and interviews with staff for 22 of 27 patients (Patients #1, #3, #4, #6, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #26) who were admitted to the psychiatry unit, nursing staff failed to develop care plans (multidisciplinary treatment plans) that were specific to each patients safety needs related to the environment and to the level of observation required to maintain safety.

In addition, for 27 of 27 patients, the hospital failed to ensure that group therapies were identified for each patient, specific to his/her needs. The findings include:

1. Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates. The patient was assessed by MD #1 (Psychiatrist) on 8/3/10 and identified with diagnoses of severe major depressive disorder, opiate dependency, borderline personality disorder and was a suicide risk. The treatment plan identified suicidal ideations/gesture due to the patient's attempt to kill his/her self and mood disorder. Interventions included to maintain a safe environment and assess suicidality daily and as needed. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #1, and failed to identify who would assess suicidality, when suicidality would be assessed, what would be done based on that assessment, and how it would be documented and communicate to others. Review of the policy for a clinical psychiatric record identified that the treatment plan would define prescribed treatment interventions. Patient #1 was placed on routine 15-minute checks and was last observed at 5:30 PM. Approximately 10 minutes later, Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. Patient #1 expired on 8/7/10 at 1:59 PM. In addition, Patient #1's clinical record identified that between 8/3/10 and 8/4/10, he/she failed to attend/participate in any group therapies including orientation and goals, post acute withdrawal, walk and talk, first step, skill building, and wrap-up.

2. Patient #3 was admitted on 8/4/10 with diagnoses of schizophrenia and psychosis, impaired judgment and a positive history of violence. The treatment plan identified psychosis as evidenced by auditory and visual hallucinations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #3 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails, once known that side rails posed a risk for hanging. On 8/9/10 the Hospital developed an immediate action plan to address safety issues on the psychiatric unit. The plan identified that nursing staff would include side rails in their environmental risk assessment and document this each shift in a progress note

3. Patient #4 was admitted on 8/9/10 with a diagnosis of severe depression and had recently overdosed with aspirin in a suicide attempt. The treatment plan identified mood disorder, poor impulse control and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #4 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

4. Patient #6 was admitted on 8/8/10 with diagnoses of depression and mood disorder and had recent suicidal and homicidal ideations. The treatment plan identified mood disorder, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #6 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/8/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

5. Patient #7 was admitted on 7/29/10 with a diagnosis of mood disorder and had recently attempted suicide, sustaining a gunshot wound. The treatment plan identified mood disorder, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #7 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

6. Patient #8 was admitted on 8/5/10 with a diagnosis of mood disorder and had recently intentionally cut self with a piece of glass in an attempt to harm his/her self. The treatment plan identified mood disorder with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #8 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/5/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

7. Patient #9 was admitted on 8/4/10 with a diagnosis of mood disorder and had recently attempted suicide by consuming an overdose of medication. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #9 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

8. Patient #11 was admitted on 7/27/10 with a diagnosis of schizophrenia. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #11 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

9. Patient #12 was admitted on 8/4/10 with diagnoses of schizoaffective disorder and dementia. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #12 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

10. Patient #13 was admitted on 8/6/10 with diagnoses of bipolar and oppositional defiant disorders, and behavioral dyscontrol. The treatment plan identified mood disorder, poor impulse control, homicidal and suicidal ideations involving a knife, with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #13 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/6/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

11. Patient #14 was admitted on 8/7/10 with a diagnosis of bipolar disorder, and manic with psychotic features. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #14 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/7/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

12. Patient #15 was admitted on 8/10/10 with a diagnosis of major depression that was severe with psychotic features. The patient was identified as suicidal after cutting his/her neck with a broken glass bottle. The treatment plan identified a mood disorder, poor impulse control, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #15 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

13. Patient #16 was admitted on 8/3/10 with diagnoses of schizoaffective disorder, borderline personality, with recent self inflicted lacerations requiring 15 staples and 8 sutures. The treatment plan identified suicidal ideations and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #16 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

14. Patient #17 was admitted on 8/10/10 with diagnoses of mood and borderline personality disorders and identified as clinically suicidal. The treatment plan identified a mood disorder, poor impulse control, and suicidal ideations with an intervention to maintain a safe environment by placing the patient on lounge restriction for safety. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10 who identified that Patient #17 was found with a knife hidden in his/her bedroom and placed on 24-hour lounge restriction for safety. The patient's mattress was brought to the lounge each night to provide a place to sleep. The lounge was observed on 8/9/10 and noted to be an open area for the general populations use and provided no privacy for a patient sleeping on a mattress in that area. The treatment plan failed to identify an appropriate environment that would be safe for Patient #17 while maintaining personal privacy and dignity.

15. Patient #18 was admitted on 7/14/10 with diagnoses of schizoaffective and borderline personality disorders, with multiple serious overdose attempts. The treatment plan identified suicidal ideations and psychosis with auditory hallucinations and delusions, with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #18 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

16. Patient #19 was admitted on 8/3/10 with a diagnosis of major depression, severe with psychotic features, with a recent attempt to cut self with a knife. The treatment plan identified suicidal ideations and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #19 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

17. Patient #20 was admitted on 8/9/10 with a diagnosis of major depression, with a recent attempt to overdose on medications, and suffocation with a plastic bag. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

18. Patient #21 was admitted on 8/3/10 with diagnoses of psychosis and personality disorder of the criminal type, with recent suicidal thoughts. The treatment plan identified suicidal ideations, mood disorder, and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #21 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

19. Patient #22 was admitted on 8/11/10 with diagnoses of bipolar disorder and depression with psychosis, with recent suicidal thoughts. Patient #22's clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Although the patient had been newly admitted and the treatment team had not yet met, the patient was placed on routine 15-minute checks. However, the record failed to reflect that an environmental assessment was conducted on admission, to identify the type of environment that would be safe for Patient #22 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

20. Patient #23 was admitted on 8/11/10 with a diagnosis of severe major depression, and had recently cut his/her wrists and throat. The treatment plan identified suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #19 and failed to include any precautions that staff should take to maintain the patient's safety, in the presence of side rails.

21. Patient #24 was admitted on 8/10/10 with a diagnosis of severe major depression with psychosis, with a recent attempt to overdose on medications, and suffocation with a plastic bag. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

22. Patient #26 was admitted on 8/9/10 with a diagnosis of major depression, with current thoughts of suicidal ideations. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

23. For 27 of 27 patients residing on the psychiatric unit, the hospital failed to ensure that treatment plans identified specific group therapies that were appropriate to each patients needs. Review of the policy for a clinical psychiatric record identified that the treatment plan would define prescribed treatment interventions including specific group or individual therapy.

Based on clinical record reviews, review of Hospital documentation, review of policies, and interviews with staff for 22 of 27 patients who were admitted to the psychiatry unit, documentation failed to reflect care plans (multidisciplinary treatment plans) that were specific to each patients safety needs related to the environment and to the level of observation required to maintain safety. The clinical record failed to identify group therapies specific to the patients needs. Please refer to A449

Based on a review of clinical records, review of Hospital documentation, review of policies, and interviews with staff for 22 of 27 patients (Patients #1, #3, #4, #6, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #26) who were admitted to the psychiatry unit, documentation failed to reflect care plans (multidisciplinary treatment plans) that were specific to each patients safety needs related to the environment and to the level of observation required to maintain safety.

In addition, for 27 of 27 patients, the clinical record failed to identify group therapies specific to the patients needs. The findings include:

1. Patient #1 was admitted on 8/2/10 after an attempted suicide by cutting his/her wrists and consuming an overdose of opiates. The patient was assessed by MD #1 (Psychiatrist) on 8/3/10 and identified with diagnoses of severe major depressive disorder, opiate dependency, borderline personality disorder and was a suicide risk. The treatment plan identified suicidal ideations/gesture due to the patient's attempt to kill his/her self and mood disorder. Interventions included to maintain a safe environment and assess suicidality daily and as needed. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #1, and failed to identify who would assess suicidality, when suicidality would be assessed, what would be done based on that assessment, and how it would be documented and communicate to others. Review of the policy for a clinical psychiatric record identified that the treatment plan would define prescribed treatment interventions. Patient #1 was placed on routine 15-minute checks and was last observed at 5:30 PM. Approximately 10 minutes later, Patient #1 was found hanging from the side rail of his/her bed with a sheet around his/her neck. Patient #1 expired on 8/7/10 at 1:59 PM. In addition, Patient #1's clinical record identified that between 8/3/10 and 8/4/10, he/she failed to attend/participate in any group therapies including orientation and goals, post acute withdrawal, walk and talk, first step, skill building, and wrap-up.

2. Patient #3 was admitted on 8/4/10 with diagnoses of schizophrenia and psychosis, impaired judgment and a positive history of violence. The treatment plan identified psychosis as evidenced by auditory and visual hallucinations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #3 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails, once known that side rails posed a risk for hanging. On 8/9/10 the Hospital developed an immediate action plan to address safety issues on the psychiatric unit. The plan identified that nursing staff would include side rails in their environmental risk assessment and document this each shift in a progress note

3. Patient #4 was admitted on 8/9/10 with a diagnosis of severe depression and had recently overdosed with aspirin in a suicide attempt. The treatment plan identified mood disorder, poor impulse control and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #4 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

4. Patient #6 was admitted on 8/8/10 with diagnoses of depression and mood disorder and had recent suicidal and homicidal ideations. The treatment plan identified mood disorder, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #6 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/8/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

5. Patient #7 was admitted on 7/29/10 with a diagnosis of mood disorder and had recently attempted suicide, sustaining a gunshot wound. The treatment plan identified mood disorder, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #7 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

6. Patient #8 was admitted on 8/5/10 with a diagnosis of mood disorder and had recently intentionally cut self with a piece of glass in an attempt to harm his/her self. The treatment plan identified mood disorder with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #8 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/5/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

7. Patient #9 was admitted on 8/4/10 with a diagnosis of mood disorder and had recently attempted suicide by consuming an overdose of medication. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #9 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

8. Patient #11 was admitted on 7/27/10 with a diagnosis of schizophrenia. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #11 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

9. Patient #12 was admitted on 8/4/10 with diagnoses of schizoaffective disorder and dementia. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Director and Assistant Director of psychiatry on 8/9/10. The plan failed to identify the type of environment that would be safe for Patient #12 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

10. Patient #13 was admitted on 8/6/10 with diagnoses of bipolar and oppositional defiant disorders, and behavioral dyscontrol. The treatment plan identified mood disorder, poor impulse control, homicidal and suicidal ideations involving a knife, with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #13 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/6/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

11. Patient #14 was admitted on 8/7/10 with a diagnosis of bipolar disorder, and manic with psychotic features. The treatment plan identified psychosis with delusions and paranoia with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #14 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/7/10 and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

12. Patient #15 was admitted on 8/10/10 with a diagnosis of major depression that was severe with psychotic features. The patient was identified as suicidal after cutting his/her neck with a broken glass bottle. The treatment plan identified a mood disorder, poor impulse control, and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #15 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

13. Patient #16 was admitted on 8/3/10 with diagnoses of schizoaffective disorder, borderline personality, with recent self inflicted lacerations requiring 15 staples and 8 sutures. The treatment plan identified suicidal ideations and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #16 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

14. Patient #17 was admitted on 8/10/10 with diagnoses of mood and borderline personality disorders and identified as clinically suicidal. The treatment plan identified a mood disorder, poor impulse control, and suicidal ideations with an intervention to maintain a safe environment by placing the patient on lounge restriction for safety. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10 who identified that Patient #17 was found with a knife hidden in his/her bedroom and placed on 24-hour lounge restriction for safety. The patient's mattress was brought to the lounge each night to provide a place to sleep. The lounge was observed on 8/9/10 and noted to be an open area for the general populations use and provided no privacy for a patient sleeping on a mattress in that area. The treatment plan failed to identify an appropriate environment that would be safe for Patient #17 while maintaining personal privacy and dignity.

15. Patient #18 was admitted on 7/14/10 with diagnoses of schizoaffective and borderline personality disorders, with multiple serious overdose attempts. The treatment plan identified suicidal ideations and psychosis with auditory hallucinations and delusions, with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #18 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

16. Patient #19 was admitted on 8/3/10 with a diagnosis of major depression, severe with psychotic features, with a recent attempt to cut self with a knife. The treatment plan identified suicidal ideations and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #19 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

17. Patient #20 was admitted on 8/9/10 with a diagnosis of major depression, with a recent attempt to overdose on medications, and suffocation with a plastic bag. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

18. Patient #21 was admitted on 8/3/10 with diagnoses of psychosis and personality disorder of the criminal type, with recent suicidal thoughts. The treatment plan identified suicidal ideations, mood disorder, and psychosis with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #21 and failed to include any precautions that staff should take to maintain the patient's safety. Between 8/4/10 at 6 PM and 8/9/10 at 7 AM, staff failed to reevaluate the patient's safety in the presence of side rails.

19. Patient #22 was admitted on 8/11/10 with diagnoses of bipolar disorder and depression with psychosis, with recent suicidal thoughts. Patient #22's clinical record was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. Although the patient had been newly admitted and the treatment team had not yet met, the patient was placed on routine 15-minute checks. However, the record failed to reflect that an environmental assessment was conducted on admission, to identify the type of environment that would be safe for Patient #22 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

20. Patient #23 was admitted on 8/11/10 with a diagnosis of severe major depression, and had recently cut his/her wrists and throat. The treatment plan identified suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #19 and failed to include any precautions that staff should take to maintain the patient's safety, in the presence of side rails.

21. Patient #24 was admitted on 8/10/10 with a diagnosis of severe major depression with psychosis, with a recent attempt to overdose on medications, and suffocation with a plastic bag. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

22. Patient #26 was admitted on 8/9/10 with a diagnosis of major depression, with current thoughts of suicidal ideations. The treatment plan identified mood disorder and suicidal ideations with an intervention to maintain a safe environment. The plan was reviewed with the nursing Assistant Director of psychiatry on 8/12/10. The plan failed to identify the type of environment that would be safe for Patient #20 and failed to include any precautions that staff should take to maintain the patient's safety, including the presence of side rails.

23. For 27 of 27 patients residing on the psychiatric unit, the hospital failed to ensure that treatment plans identified specific group therapies that were appropriate to each patients needs. Review of the policy for a clinical psychiatric record identified that the treatment plan would define prescribed treatment interventions including specific group or individual therapy.

Based on a tour of the Behavioral Health unit located on the 8th floor and the Behavioral Health holding area in the Emergency department, review of hospital documentation, review of policies, and staff interviews, the hospital failed to ensure a safe environment.
The following are a list of findings based on the above:

a. The facility installed non-breakaway clothes hanging hooks on the interior of patient wardrobe closets;
b. The facility installed doors on patient wardrobe closets which had hinges that pose a risk for strangulation, these hinges were identified as a risk on April 30, 2010 by the facility Environment of Care Committee annual risk assessment of the Behavioral Health Unit and to date have not been further addressed;
c. The facility installed door knobs on patient bathrooms within the patient rooms which pose a risk for strangulation, these door knobs were identified on April 30, 2010 by the facility Environment of Care Committee annual risk assessment of the Behavioral Health Unit and to date have not been further addressed;
d. The facility installed surface mounted hand towel dispensers in all double patient rooms which pose a safety hazard as these dispensers can be used as a weapon;
e. The facility installed locks on all patient bedrooms with thumb style turn knobs on the interior of the patients door, these knobs pose a risk for strangulation as they were mounted in the upright position;
f. The door to the patient area washer/dryer room was unlocked. An interview with the Assistant Director of the Behavioral Health unit at the time of this finding identified that this door is always kept unlocked. The washer/dryer room is considered a hazardous area due to it having an automatic closing device on the interior of the door, two (2) hoses connected to water pipes, a ventilation pipe connected to the dryer which was very hot at the time, and high voltage receptacle within the room;
g. An interview with the Director of Engineering / Chairperson of the Environment of Care Committee identified that on May 19, 2010 an EOC committee meeting was held and the Annual Environment Risk Assessment of the Behavioral Health unit was reviewed, the risks/issues which were identified were deemed not feasible for correction and the item was closed. The Chairperson failed to report these issues to the Quality and Safety Committee as required by the facility's Environment of Care Safety Program Policy section IV item #5.