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Based on document review and interview, it was determined, for 1 of 1 patient death review (Pt. #1) the Hospital failed to ensure the patient was cared for in a safe environment, resulting in the death of a patient.

The cumulative effect of this systemic practice resulted in the Hospital's inability to ensure patient safety was maintained. As a result, 42 CFR 482.13 Condition of Participation - Patient Rights was not in compliance. This potentially affected approximately 48 patients daily receiving care on the behavioral health units (3 east and west).

Findings include:

1. The Hospital failed to ensure the patient was monitored every 15 minutes as required. This potentially affected the safety of all suicide risk patients on the unit (A-144).

The immediate jeopardy began on 08/18/14, (identified 08/28/14) when the Hospital failed to ensure staff consistently perform required patient safety rounds.

Pt. #1 was a 43-year-old female, admitted on 8/16/14 with the diagnosis of Major Depression. Certificate and Petition information in the clinical record dated 8/16/14 at 4:15 P.M., included that Pt. #1 was " found on a bridge about to jump off ... calling Mom to say she loves her in case anything happens to her " . The clinical record included a physician's order dated 08/16/14 for suicide precautions, which required safety round observation and documentation every 15 minutes. Review of video surveillance revealed that although staff had documented safety rounds for Pt. #1, every 15 minutes on 08/18/14 from 6:00 P.M.-8:30 P.M., the checks had not actually been performed. Pt. #1 was later found lying unresponsive in the shower room. A Code Blue was called, and resuscitative measures attempted, but Pt. #1 was not able to be revived.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of this systemic practice. The CNO and CEO were notified in person of the immediate jeopardy on 8/28/14 at 4:20 PM. The immediate jeopardy was not removed by the exit date because the Hospital failed to completely implement sufficient measures to ensure patient safety and non reoccurrence.

Based on document review and staff interview, it was determined for 1 of 4 (Pt. #1) patients on suicide precautions, the Hospital failed to ensure the patient's safety rounds were performed every 15 minutes as required, potentially affecting the safety of all patients on the unit.

Findings include:

1. Hospital policy titled, "Suicide Precautions/Risks (reviewed 4/14)" required, "Suicide precautions include the observation and documentation of the patient's location and behavior at least every 15 minutes."

2. The clinical record of Pt. #1 was reviewed on 8/25/14. Pt. #1 was a 43 year old female admitted on 8/16/14 with the diagnosis of Major Depression. A physician's order dated 8/16/14 at 11:00 PM included suicide precautions. The clinical record contained completed patient safety records indicating Pt. #1 had been monitored every 15 minutes per policy, continuously from admission on 8/16/14 through 8/18/14 at 8:30 P.M..

3. A nurse's note dated 8/18/14 at 10:00 PM included, "Patient name was called for medication, checked the bed and the room, patient was not visible. Shower room door was closed and writer was unable to get in, MHS (mental health specialist) called to check patient in the shower room. MHS got in the shower room, patient lying on the floor, faint pulse noted, rapid response team called, patient pulled out of shower, unresponsive - code blue called. "

4. The physician who responded to the code (MD#2's) progress note dated 8/18/14 at 9:53 P.M. included, "received call from nurse on the unit 3 East. According to nurse, patient was found unresponsive in the bathroom. Code blue was called and resuscitation efforts were made, but patient could not be revived."

5. The surveillance video of the 3 East nursing unit hallway on 8/18/14 from 6:00 P.M. until 10:00 P.M. was viewed on 8/26/14 at 1:15 P.M. The video showed no one performing safety rounds on Pt. #1. The nurse did go Pt. #1's room at approximately 8:35 P.M. and called the MHS to assist.

6. The Chief Nursing Officer (E#3) was interviewed on 8/26/14 at 10:45 A.M. E#3 stated after viewing the video it was very clear that the staff had falsified the records and safety rounds on Pt. #1 were not performed.