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Based on observations, interview and documentation review it was determined the Hospital failed to ensure patient's on suicide precautions received care in a safe setting in one out of 11 applicable patient medical records reviewed.

Findings included:

Documentation review indicated Patient #1, who had a history of previous suicide attempts, was admitted the the Hospital after ingestion of an unknown quantity of Asprin, sleeping pills, and Tylenol pill in a suicide attempt. A psychiatric consultation was performed and an application for a temporary involuntary hospitalization was filed. Patient #1 could not leave the Hospital and 1:1 observation was initiated After treatment in the ED Patient #1 was admitted to the medical intensive care unit (MICU) on 9/24/10 at 1:00 PM for continued medical treatment and monitoring. The 1:1 observation was maintained. On 9/26/10 Patient #1 had improved medically and was transferred to a medical nursing unit. The 1:1 observation was to continue. The treatment plan included a psychiatric admission and once medically cleared a bed search would be initiated. Patient #1 arrived on the medical nursing unit at 2:00 PM. The Attending Physician, found Patient #1, at 5:35 PM, unresponsive in the bathroom after an apparent suicide attempt. Patient #1 did not have a pulse on initial evaluation and his/her neck/face were purplish-blue in color were the shower hose was wrapped at the neck; CPR was immediately initiated. It was noted on arrival in Patient #1's room it was empty the nursing staff member assigned to provided 1:1 observation reported Patient #1 went to the bathroom and shut the door, and he/she had gone to get help.

The Hospital policy that addressed 1:1 observation was reviewed. The Policy stated all patients on suicide precautions will have a constant observer assigned. The Patient environment will be made safe by removing potentially dangerous items form the room including but not limited to IV tubing, Kerlex, sharp or potentially sharp objects.

A tour of the Medical Nursing Unit was conducted on 10/5/10 at 1:20 PM. It was observed all patient room had a bathroom that included a shower. Shower heads were mounted on a flexible hose approximately 3 feet long. The shower head could be removed from a mounted holder allowing the hose to be extended to its full length.

The Nursing Director for the medical in-patient nursing units was interviewed in person on 10/5/10 at 10:50 AM. He/she said the medical nursing unit did occasional have patients, on suicide precautions, with medical issues who need to be stabilized before they can be transferred to a psychiatric facility. He/she said no one had ever identified the shower hose as a safety issue until this incident.

The Patient Care Assistant, assigned to provide Patient's 1:1 observation on 9/26/10 was interviewed in person on 10/5/10 at 10:30 AM. He/she said Patient #1 had suddenly pulled out the Foley catheter and the IV, jumped out of bed, walked very quickly to the bathroom and closed the door. The Patient Care Assistant said he/she was seated in the doorway of Patient #1's room when he/she observed all this and had walked to the bathroom after Patient #1. He/she said upon request to open the door Patient #1 had refused. He/she said he/she tried to open the door from the outside but could not because Patient #1 must have been holding the door tight. When she/she could not open the door he/she left the room to find and get help from another staff member.

The Patient Care Assistant's personnel and education files were reviewed. The files did not indicate the Hospital provided education related to the duties of a staff member performing 1:1 observation of a patient who was on suicide precautions.

The Executive Director of Risk Management was interviewed on 10/6/10. He/she said during the Hospital's review of this incident it was identified, that although the Hospital's ED had a formal process for education of staff member who were part of the float pool and provided 1:1 observation for patient's in the ED, there was no formal education program in place for the patient care assistants permanently assigned to an in patient nursing unit, who proved 1:1 observation of patients.

Based on interview and documentation review it was determined the Hospital failed to ensure the nursing care of each patient was assigned in accordance with the patient's needs and the competence of the nursing staff available.

Refer to Tag # 0144