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Based on record review, interview and policy review, the facility failed to provide adequate supervision to prevent a patient from harming themselves. This affected Patient #1.

See A395

Based on record review, interview and policy review, the facility failed to provide adequate supervision to prevent a patient from harming themselves. This affected one (Patient #1) of ten records reviewed.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 05/14/24. Patient #1 was admitted for attempting to harm herself by choking herself and or running into traffic. Patient #1 was assigned a one-on-one sitter on admission.

On 06/13/24 at approximately 12:30 A.M. Patient #1 was found with underwear tied around her neck. Patient #1 was unconscious with ligature marks around her neck. The nursing staff heard gurgling coming from her room and they entered the room and began removing the underwear from her neck. She was found with a faint pulse. She eventually regained consciousness, and a code was called. Patient #1 was sent to a general medical floor for observation and returned to the unit on 06/14/24. When Patient #1 returned to the unit she was ordered a two-to-one observation. Patient #1 had no further issues and was participating in therapies and groups and making progress toward her mental health goals.

Patient #1 was downgraded to a one-on-one sitter on 07/03/24. On 07/04/24 at approximately 10:00 P.M. the nurse was called to Patient #1's room and she was found with her hands under the covers. The nurse instructed Patient #1 to move her hands out from the covers and Patient #1 informed the nurse she was fine. Approximately 20 minutes later the sitter informed the nurse he was hearing gurgling noises coming from Patient #1 and the nurse went into assess Patient #1 and found material wrapped around her neck. A code was called, and the nurse removed the material and Patient #1 was sent to the intensive care unit for monitoring. Patient #1 returned to the unit on 07/05/24 and has remained there since. Patient #1 was ordered a permanent two-to-one observation.

During an observation on 08/14/24 at 1:10 P.M., Patient #1 was sitting in the common area with two staff members watching her. One staff member was sitting directly in full view of Patient #1 and the other was sitting directly behind Patient #1 with in arm's reach.

During an interview on 08/15/24 at 8:18 A.M., Division Director of Inpatient Psychiatric Staff J, Medical Director Staff K, and Behavioral Health Service Line Director Staff L confirmed that the facility did investigate the incidents regarding Patient #1. They reported while they were investigating the first incident, Patient #1 attempted it again, so they rolled both investigations into one. They reported no concerns with their findings and reported that before each incident Patient #1 had been displaying behaviors that showed improvement and was actively participating in group therapies and being a model patient. They confirmed she is now on a two to one supervision no matter how well she is acting, and they are working with community resources to get her placed. Staff L confirmed that the actions of the staff showed room for improvement.

During a telephone interview on 08/15/24 at 8:29 A.M., RN Staff M revealed she was on the unit for both instances regarding Patient #1. She reported that on 06/13/24 she was not assigned to be Patient #1's nurse but around midnight she was sitting at the nurse ' s station with two other nurses and they all could hear a gurgling sound. The sound came back, and they all ran to check to see where it was coming from. Patient #1 had a sitter that was sitting in the hallway looking into her dark room. Patient #1 was found unresponsive with her underwear tied around her neck. Code blue was called, and the staff immediately removed the underwear from her neck and began assessing her. She did have a pulse and became arousable. Patient #1 was then sent to a medical floor for observation. Staff M revealed that when Patient #1 returned to the unit she was placed on a two-on-one observation and was ordered to always keep her hands and arms outside of her blankets. Patient #1 was showing improvement and started participating in group therapies and talking out her triggers. Patient #1 met the criteria to be downgraded to a one-to-one sitter on 07/03/24 and on 07/04/24 she was the nurse assigned to Patient #1. She confirmed Patient #1 had a sitter who was sitting outside of her room looking in. The sitter alerted her that he could hear tearing noises around 10:00 P.M. She went into the room and Patient #1 had both of her arms under her blankets and she reminded her that her hands needed to always be out of her covers. Approximately 20 minutes later the sitter alerted her again that she was making strange noises. Staff M walked into the room turned on the lights and found cloth wrapped around Patient #1's neck and she was not responding. She immediately told the sitter to call a code blue, and she removed the cloth from around Patient #1's neck. Patient #1 became conscious and there were ligature marks on her neck. The cloth was found to be the ripped waistband from her pants. She reported that at that time Patient #1 was taken to the intensive care unit for observation and was laughing as she left the unit. She confirmed that now Patient #1 is always a two-to-one, with one staff member at arm's length always and the other watching from the doorway.

During a telephone Interview on 08/15/24 at 8:46 A.M., Clinical Coordinator Staff O confirmed she was working both nights that Patient #1 had an incident. She reported on 06/13/24 she was in her office when she heard commotion outside of Patient #1's room. She went to Patient #1's room and found out that Patient #1 had been found with her underwear tied around her neck. Patient #1 did have a sitter that night who was from the float pool. Before Patient #1 was transferred to the general medical floor for observation Patient #1 informed her that she was not being watched and went into the bathroom removed her underwear and took them back to bed with her to tie around her neck. The sitter was interviewed by Staff O and the nursing supervisor and reported that she was not trained to watch the kids. She reported that more staff education was completed. Staff O also confirmed that after Patient #1 returned to the unit she began showing signs of improvement. She was downgraded from a two-to-one supervision to a one-to-one supervision. She confirmed her sitter on the night of 07/04/24 had been reporting to the nurse that he heard ripping noises, Patient #1 was assessed and then when he heard gurgling noises, she was assessed again and was found to have fabric wrapped around her neck. A code was called and after Patient #1 became responsive again she reported that she ripped her shorts and hid the fabric in her scrub top pocket so she could do this during the night. Patient #1 reported she had nothing wrong she was just mad she did not have two sitters anymore and she had too much freedom that day.

During a telephone interview on 08/15/24 at 10:23 A.M., Sitter Staff P confirmed she was the sitter for Patient #1 on 06/13/24. She reported during the shift she had a conversation with Patient #1 and Patient #1 reported she snored in her sleep. Patient #1 was reporting to her that she did not want to go to sleep, and she encouraged her to try. Patient #1 then went to the restroom. Staff P confirmed that she did not go into the restroom with her because during her orientation she was informed she did not have to go into the restrooms with patients when they were on one to ones. She then reported Patient #1 came out of the restroom and began asking for a behavioral health technician. The technician did come and speak with Patient #1 and encouraged her to go to sleep and Patient #1 laid down. She eventually did settle and began making noises like snoring and Staff P thought nothing of it because Patient #1 reported she snored. Staff P reported the snoring did get louder and the nursing staff did come into the room and found Patient #1 with her underwear tied around her neck.

During interview on 08/15/24 at 2:00 P.M. with Staff F and L revealed after the investigation they trained all staff. They also revamped the nurse-to-nurse report which has increased communication between staff shift changes. They included significant events and admission diagnosis, and circumstances were added. Policies were reviewed but have not been reviewed by all parties. In June 2024 staff meeting the nurse educator spoke to all the staff on the role of a one-on-one sitter. They also have assessed the patient care plan and made changes to her care. The behavior plan care conference for Patient #1 was also attended by all staff and was recorded for staff to view not available to attend. They facility also met with the electronic medical record team to see if they could improve the documentation for one-on-one staff.

During interview on 08/15/24 at 4:00 P.M., Staff C confirmed that the plan of action has not been completed. She reported that all staff has been educated but the facility has not finished reviewing all policies or making changes to documentation as it stated.

Review of the facility root cause analysis revealed the facility met 06/17/24 to discuss the incidents, again on 07/01/24, and 07/16/24. Administrative staff was present, and they determined action plans.

Review of the facility action plan revealed no start date and revealed it was projected to be completed on 08/30/24.
Review of the facility policy titled "Patient Care Companion", effective 05/05/22, revealed constant visualization of the patient by a patient care companion who is assigned only to one patient. The patient must always be in the line of sight of the staff member, including when the patient is sleeping, in the bathroom and shower, and when off the unit for tests or a procedure.