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Based on review of the medical record, policies and procedures, camera review, and staff interviews and written statement, it was determined that the facility failed to establish an effective system to ensure that the patient's condition was monitored for continuous safety for 1 of 1 (#1) patient whose record was reviewed.

Review of the medical record for patient #1 revealed that the adolescent patient was a voluntary admission to the facility's Child & Adolescent Unit. The admission forms, consents and authorization for treatment were signed by the patient's parents. The admission physician orders required that the patient be placed on close observation precautions. The rationale for the precaution was patient at risk for suicide. Nursing documentation revealed that the patient was admitted to the unit at approximately 11:00 a.m. on 03/05/11, and the close observation precautions were initiated at the time of admission. The patient was seen by a psychiatrist the day following admission and a psychiatric evaluation was completed. A history and physical examination was also performed by a medical physician. Review of additional physician orders revealed that no change in the patient's level of observation was ordered by the physicians during the patient's hospitalization.

Facility policy #EC.034 , entitled "Levels of Observation", last revised 08/10, required observation of the patient every fifteen (15) minutes for close observation precautions.

Documentation in the patient's record on the special precautions rounds sheets indicated that the patient was visually observed every fifteen (15) minutes as required for close observation precautions. Documentation for 03/06/11 reflected that the patient was observed in his/her room during every 15 minute rounds between the hours of 6:30 p.m. and 8:15 p.m. Documentation on the code flow sheet indicated that the patient was found unresponsive at 8:30 p.m. in full cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated and the Emergency Medical System (EMS) was called. The EMS arrived and took over responsibility for the care of the patient. Nursing progress notes documentation reflected that when the nurse entered the patient's room, the patient was on the floor with towels around his/her throat. The towels were unwrapped and CPR initiated. The patient was transported by EMS to a local children's acute care hospital.

Interview with and a written statement provided by the Director of Nursing DON on 03/16/11 at 3:30 p.m. revealed that the patient was found by a Mental Health Assistant (MHA) in his/her room hanging from the bathroom door. A bed sheet and towels were found and removed from the patient. The patient was unresponsive without pulse and respirations. The DON and Assistant Administrator reported to the facility within the hour and an internal investigation was initiated. The patient's attending physician notified the facility on 03/09/11 that the patient had died after admission to the children's acute care hospital.

A camera review was conducted at 9:35 a.m. on 03/16/11, with the facility's Assistant Administrator. The review occurred in his/her private office. The review was limited to the activity on the the Child and Adolescent Unit on 03/06/11 between the hours of 6:11 p.m. and 8:53 p.m. The review revealed that patient #1 remained in his/her room on the unit during this time period. Patient rounds were not performed on the hall where patient #1 was located from 6:45 p.m. - 7:51 p.m. and the required every fifteen (15) minute observation of the patient was not done. At 7:51 p.m. the other patients on the unit were called out of their rooms to attend a group session in the day room. Patient #1 did not exit his/her room at this time. Employee #7 was observed at the doorway of patient #1's room at 7:56 p.m. talking with the patient. Observation of the patient was not performed again until 8:43 p.m. when employee #5 entered the patient's room and exited calling for help. The EMS technicians arrived at 8:45 p.m. and left the facility at 8:53 P.M. with the patient. CPR was in progress.

At the completion of the camera review, the Assistant Administrator confirmed that the review verified that patient #1 had not been visually observed every 15 minutes as documented on the special precautions rounds sheets, in the patient's medical record.

The following Corrective Action Plan was initiated by the facility:

Effective 03/06/2011 - Additional staff added over indicated staffing per grid for night shift on child and adolescent unit.

Effective 03/07/11 - Additional managers added to evening shift to assist House Supervisor with auditing observation rounds.

Effective 03/08/11 - Time parameters for manager evening shift rounds narrowed to be performed between the hours of 7:00 p.m. and 11:00 p.m.

Effective 03/09/11 - Regular and PRN (used as necessary) Charge Nurse education/re-education regarding:
1. Assignment conducive to completion of rounds.
2. Supervision of conducting rounds with mental health assistant/staff member assigned and
initialing the ones manually supervised and conducted with the mental health
assistant/assigned staffed member.
3. Importance of monitoring patients who are isolated from the main group of patients due to
illness, etc. and are allowed access to their rooms.

Effective 03/09/11 - A schedule was developed to outline the manager's rounds seven days per week/3 shifts per day. These rounds are being completed in addition to the night shift video surveillance rounds and the bi-weekly manager evening shift rounds.

Effective 03/09/11 - Director of Nursing has developed a spreadsheet to track staff who have had rounds checked and the date they were checked so that rounding efforts can be targeted to ensure the boards of all facility staff members are checked.

Effective 03/07/11 - Privacy curtains and racks ordered to replace all bathroom doors on the child and adolescent unit. Materials scheduled to be delivered on 03/10/11; removal of curtain bathroom doors and replacement with privacy curtain to be performed 03/11/11 - 03/13/11. Additional materials ordered to continue with replacement of bathroom doors on all units. Next unit scheduled is the adult unit.

*All bathroom doors on youth services and armoire doors were removed as of 03/14/11.

Effective 03/15/11 - A separate schedule was developed to account for manager rounds (non-nursing supervisor managers) seven days per week, three shifts per day in addition to the rounds being made by the nursing clinical supervisor team. This provides for two un-announced rounds per shift seven days per week.

Target Implementation Date of 03/28/11 - Culture Change Campaign to emphasize moral obligation to patient safety and patient rounds. Employee oath/promise/creed to conduct patient rounds will be developed. All clinical staff members will sign the oath. Professional posters will be produced and posted through out the facility to Honor/Remember the oath. The oath will be posted in employee-only areas.

Based on review of the medical record, policies and procedures, facility tour, and staff interviews, it was determined that the facility failed to establish an effective system to ensure that the patient's condition was supervised and evaluated to provide for continuous safety for 1 of 1 (#1) patient whose record was reviewed.

Review of the medical record for patient #1 revealed that the adolescent patient was a voluntary admission to the facility's Child & Adolescent Unit. The admission forms, consents and authorization for treatment were signed by the patient's parents. The admission physician orders required that the patient be placed on close observation precautions. The rationale for the precaution was patient at risk for suicide. Nursing documentation revealed that the patient was admitted to the unit at approximately 11:00 a.m. on 03/05/11, and the close observation precautions were initiated at the time of admission. The patient was seen by a psychiatrist the day following admission and a psychiatric evaluation was completed. A history and physical examination was also performed by a medical physician. Review of additional physician orders revealed that no change in the patient's level of observation was ordered by the physicians during the patient's hospitalization.

Facility policy #EC.034 , entitled "Levels of Observation", last revised 08/10, required observation of the patient every fifteen (15) minutes for close observation precautions.

Documentation in the patient's record on the special precautions rounds sheets indicated that the patient was visually observed every fifteen (15) minutes as required for close observation precautions. Documentation for 03/06/11 reflected that the patient was observed in his/her room during every 15 minute rounds between the hours of 6:30 p.m. and 8:15 p.m. Documentation on the code flow sheet indicated that the patient was found unresponsive at 8:30 p.m. in full cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated and the Emergency Medical System (EMS) was called. The EMS arrived and took over responsibility for the care of the patient. Nursing progress notes documentation reflected that when the nurse entered the patient's room, the patient was on the floor with towels around his/her throat. The towels were unwrapped and CPR initiated. The patient was transported by EMS to a local children's acute care hospital.

Interview with and a written statement provided by the Director of Nursing DON on 03/16/11 at 3:30 p.m. revealed that the patient was found by a Mental Health Assistant (MHA) in his/her room hanging from the bathroom door. A bed sheet and towels were found and removed from the patient. The patient was unresponsive without pulse and respirations. The DON and Assistant Administrator reported to the facility within the hour and an internal investigation was initiated. The patient's attending physician notified the facility on 03/09/11 that the patient had died after admission to the children's acute care hospital.

A camera review was conducted at 9:35 a.m. on 03/16/11, with the facility's Assistant Administrator. The review occurred in his/her private office. The review was limited to the activity on the the Child and Adolescent Unit on 03/06/11 between the hours of 6:11 p.m. and 8:53 p.m. The review revealed that patient #1 remained in his/her room on the unit during this time period. Patient rounds were not performed on the hall where patient #1 was located from 6:45 p.m. - 7:51 p.m. and the required every fifteen (15) minute observation of the patient was not done. At 7:51 p.m. the other patients on the unit were called out of their rooms to attend a group session in the day room. Patient #1 did not exit his/her room at this time. Employee #7 was observed at the doorway of patient #1's room at 7:56 p.m. talking with the patient. Observation of the patient was not performed again until 8:43 p.m. when employee #5 entered the patient's room and exited calling for help. The EMS technicians arrived at 8:45 p.m. and left the facility at 8:53 P.M. with the patient. CPR was in progress.

At the completion of the camera review, the Assistant Administrator confirmed that the review verified that patient #1 had not been visually observed every 15 minutes as documented on the special precautions rounds sheets, in the patient's medical record.

The following Corrective Action Plan was initiated by the facility:

Effective 03/06/2011 - Additional staff added over indicated staffing per grid for night shift on child and adolescent unit.

Effective 03/07/11 - Additional managers added to evening shift to assist House Supervisor with auditing observation rounds.

Effective 03/08/11 - Time parameters for manager evening shift rounds narrowed to be performed between the hours of 7:00 p.m. and 11:00 p.m.

Effective 03/09/11 - Regular and PRN (used as necessary) Charge Nurse education/re-education regarding:
1. Assignment conducive to completion of rounds.
2. Supervision of conducting rounds with mental health assistant/staff member assigned and
initialing the ones manually supervised and conducted with the mental health
assistant/assigned staffed member.
3. Importance of monitoring patients who are isolated from the main group of patients due to
illness, etc. and are allowed access to their rooms.

Effective 03/09/11 - A schedule was developed to outline the manager's rounds seven days per week/3 shifts per day. These rounds are being completed in addition to the night shift video surveillance rounds and the bi-weekly manager evening shift rounds.

Effective 03/09/11 - Director of Nursing has developed a spreadsheet to track staff who have had rounds checked and the date they were checked so that rounding efforts can be targeted to ensure the boards of all facility staff members are checked.

Effective 03/07/11 - Privacy curtains and racks ordered to replace all bathroom doors on the child and adolescent unit. Materials scheduled to be delivered on 03/10/11; removal of curtain bathroom doors and replacement with privacy curtain to be performed 03/11/11 - 03/13/11. Additional materials ordered to continue with replacement of bathroom doors on all units. Next unit scheduled is the adult unit.

*All bathroom doors on youth services and armoire doors were removed as of 03/14/11.

Effective 03/15/11 - A separate schedule was developed to account for manager rounds (non-nursing supervisor managers) seven days per week, three shifts per day in addition to the rounds being made by the nursing clinical supervisor team. This provides for two un-announced rounds per shift seven days per week.

Target Implementation Date of 03/28/11 - Culture Change Campaign to emphasize moral obligation to patient safety and patient rounds. Employee oath/promise/creed to conduct patient rounds will be developed. All clinical staff members will sign the oath. Professional posters will be produced and posted through out the facility to Honor/Remember the oath. The oath will be posted in employee-only areas.