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Based on medical record review, policy review and interview, the facility did not ensure a lethality or suicide risk assessment was performed for Patient #2 or that continuous observation was provided and adequately communicated to staff caring for the patient in accordance with facility policy and physician order. Failure to conduct an assessment and provide for appropriate interventions has the potential for placing the patient at risk.

Findings include:

Review of transfer documentation received from the transferring facility revealed the patient was transferred from a facility where an involuntary admission on a medical certificate (2 PC) was in effect due to suicidal ideation.

Review of the physician history and physical dated 09/19/16 at 7:00 PM revealed the patient was transferred due to chest pain. Past medical history included depression with suicidal ideation. Prior to transfer the patient had been on 1:1 observation.

Review of the nursing assessment dated 09/19/16 at 7:09 PM revealed the patient was admitted due to chest pain with a mental health history of depression, past psychiatric hospitalizations and post- traumatic stress syndrome.

Review of physician order dated 09/19/16 at 4:38 PM revealed an order for sitter/private duty nurse.

Review of the nursing documentation revealed a "sitter was present" with the patient from 4:45 PM on 09/19/16 until 6:38 AM on 09/20/16. The nursing shift report dated 09/20/16 indicates at 06:39 AM "sitter due to suicide precautions" .

Review of nursing note dated 09/20/16 at 4:11 PM revealed at 1:30 PM the writer was called to Patient #2 's room because of yelling. The sitter was holding on to Patient #2 's arm because she had gone out of the window, with her body outside and only her arm hanging back into the room. Multiple staff rushed in and pulled the patient to safety.

Interview with Staff #6 on 11/01/16 at 2:15 PM and on 11/02/16 at 2:30 PM indicated per the change of shift report on 09/20/16 that the patient had suicidal ideation (SI) at the transferring facility and needed to be on 1:1 observation. It was noted that the patient's behavior was calm at the beginning of the shift and a little more anxious later in the shift, however, a Suicide Risk Assessment was not conducted.

Interview on with Staff #7 on 11/02/16 at 10:00 AM indicated that while Patient #26 was being helped with washing and dressing, Patient #2's reflection in the window could be seen through the mesh curtain. Patient #2 said, "Screw this, I can't take it anymore." At that time, Staff #7 pulled the curtain and grabbed Patient #2 who was on her back and almost out the window. Additional staff responded and the patient was pulled back inside.

Interview with Staff # 14 on 11/02/16 at 12:00 PM indicated she was called from another floor to sit with Patient #26 and just assist Patient #2 with the bathroom. Both patients were in the same room. She stated she got her instructions from another aide. When Staff #7 arrived to relieve her, Staff #14 briefed her about both patients. Staff #14 stated she was not notified that Patient #2 needed a 1:1 or had suicidal ideation.

Review of physician orders for Patient #26 revealed no evidence of an order for a "sitter".

Interview with Staff #1 on 11/02/16 at 9:00 AM indicated there was no suicide risk assessment by the nurse.

Interview with Staff #33 on 11/03/16 at 1:00 PM indicated the patient was on 2PC status at the transferring hospital.

Review of the "Sitter" job description dated 07/2014 indicates Sitters may provide care to the patient that does not interfere with the ability to maintain continuous visual contact. Clinical Assistants (CA) assigned as sitters will complete all aspects of activities of daily living for all patients in the room. Sitters remain in the patient 's room with an unobstructed view of the patient. The sitter accompanies the patient for any clinical tests or procedures off the unit. The sitter remains within an arm's length distance of the patient unless otherwise directed by the person performing the test or procedure. The sitter may be assigned to monitor two patients in the same room. The sitter positions him/herself to maintain an unobstructed view of both patients. Additional staff must be provided if patient activity prevents the sitter from simultaneously monitoring both patients.

Review of policy #SS.400 "Suicide Precautions" last revised 12/2016 revealed the following factors have been associated with increased suicidal risk: The presence of psychiatric illness, depression or psychosis, the presence of a medical illness associated with pain and or disability, the presence of or history of alcohol and/or drug abuse, the verbalization and/or presence of a suicide plan with the intention and means to carry it out. Patients who have risk factors and clues that put them at risk for suicide should be assessed by the registered nurse using the Suicide Risk Assessment. A detailed description of risk factors and clues as presented by the patient should be placed in the medical record. Notify the attending physician of assessed risk factors and clues. The physician may order a psychiatric consult. Document the assessment, who was notified, the time and all interventions initiated. The patient should be constantly attended by personnel, a family member, significant other person or paid sitter.

Although the patient was noted to have suicidal ideation there is no evidence to indicate that a Suicide Risk Assessment was performed, that adequate information was communicated to the sitter or that continuous observation was provided in accordance with facility policy.