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Based on review of facility policies and procedures, medical records, incident logs and staff interviews facility staff failed to ensure investigation of adverse patient events for 2 of 2 records reviewed with adverse patient events (#46, #47).

Findings included:

1. Review on 03/28/2012 of facility policy "Sentinel Event" dated 07/2009 revealed "Definition...The following are examples of a sentinel event, including but not limited to...Suicide of a patient...within 72 hours of discharge." Further review revealed "Procedure...7. A root cause analysis is conducted by a selected multidisciplinary team and completed within 45 days of discovery of a sentinel event."

Closed record review on 03/28/2012 for Patient #46 revealed a 52 year old admitted to the facility's behavioral health unit on 11/15/2010 for substance abuse detox. Review revealed Patient #46 was discharged from the facility 11/20/2010.

Further record review on 03/28/2012 of an EMS report dated 11/22/2010 for Patient #46 (two days after patient's discharge from the hospital) revealed "History of Present Illness...pt (patient) leaned up against a tree approx (approximately) 50 yards behind house w/a (with a) single gunshot wound to the head...pts (patients) wife adv (advised) that she came outside looking for husband at barn and found him lying up against a tree, it is unknown when pt shot himself."

Interview with facility administrative staff on 03/28/2012 at 1510 revealed the facility was notified on 11/24/2010 that a staff member saw an obituary for Patient #46 in the newspaper. Interview revealed the EMS report was obtained which revealed the patient had committed suicide within 72 hours of discharge from the hospital. Interview revealed this patient's death met the criteria for a sentinel event, according to facility policy. Interview revealed the facility did not conduct a root cause analysis of the patient's suicide. Interview failed to reveal why the facility did not conduct a root cause analysis of the patient's suicide. Interview revealed the facility failed to follow policy regarding investigation of a known sentinel event.

2. Review on 03/28/2012 of facility policy "Quality Indicators" dated 03/2009 revealed "Policy - It is the policy of (facility name) to strive to continuously improve all processes and services that support the care of our patients. (Name of facility) supports a non-punitive environment for employees to report unwanted occurrences or events..." Further review revealed "Examples of events that should be reported include...1. AMA/elopement..." Further review revealed "Procedure - 1. The person who discovers the occurrence should report all unwanted events on the Quality Indicator form...3. The event will be reviewed to determine the need for immediate follow up and analyzed for patterns and trends indicating a systemic process issue."

Closed record review on 03/28/2012 for Patient #47 revealed a 39 year old admitted to the facility's behavioral health unit on 10/21/2012 as an involuntary commitment for suicidal ideations. Review of nursing documentation dated 10/22/2010 at 1030 revealed "...Pt had left unit (escaped) via back door of unit. Noted on camera @ 0910. Propped door open (symbol for 'with') shoe (Pt caught door before it clicked close (symbol for 'after') staff left). Brought back to unit by outpatient registration staff @ 0943..."

Review of a form "Inpatient Charge Nurse Report" dated 10/22/2010 revealed "...5. List specific Staff Concerns: (name of Patient #47) escaped out fire exit, came right back."

Interview with facility administrative staff on 03/28/2012 at 1520 revealed the risk management department was not made aware of the patient's elopement. Interview revealed the incident should have been reported on a Quality Indicator form to notify the department. Interview revealed staff failed to follow facility policy by failing to report a successful patient elopement and failed to follow facility policy by failing to conduct an investigation for any process improvements of a successful patient elopement.

Based on review of facility policies and procedures, medical records and staff interviews, nursing staff failed to: ensure a suicide risk assessment was completed for 1 of 3 open records reviewed (#40); ensure a physician's order for a change in psychiatric safety supervision level for 1 of 6 records reviewed (#47); and ensure documentation of the reason the patient did not attend therapeutic groups for 4 of 6 records reviewed (#38, #46, #47, #45).

Findings included:

A. Review on 03/28/2012 of facility policy "Suicide Assessment/Prevention" revised 09/2011 revealed "Policy...The following patient populations will be assessed for suicide risk: All patients with a primary psychiatric diagnosis, All patients who verbalize clear intent and/or have a plan to commit suicide or have command hallucinations to harm themselves..." Further review revealed "Procedure: A...1. Patients are screened at the point of arrival in the hospital: ED...2. If the screen is positive...Consult Behavioral Services Assessment Team...B. The Assessment Team will Assess Risk Potential Using (Name of Facility) Suicide Assessment and Behavioral Services Admission Data Base...High Risk Inpatient (Score > 21)..."

Open record review on 03/29/2012 at 1515 for Patient #40 revealed a 23 year old admitted 03/29/2012 at 0300 as an involuntary commitment for major depressive disorder and post-traumatic stress disorder. Review of the physician History and Physical dated 03/29/2012 revealed "...The patient is a 23 year old single white male admitted to Psychiatry through the Emergency Department where he had presented after having made a suicide attempt by cutting his arm. He was placed on involuntary status due to suicidal behavior." Review of triage documentation in the Emergency Department on 03/28/2012 at 2322 revealed "Psychiatric triage assessment: Pt brought by paramedics for psychiatric evaluation. pt (patient) states Pt has been depressed for 'all my life'...Pt shut himself in bathroom at aunt's house and cut arm...Suicide Risk Screening: Confirms history of depression and admits thoughts of hurting self or others...Mental Status Assessment...Intent/Ambivalence: no intent to die, Lethality or Attempt or plan: None ideation only...Suicide Risk Factor: Low Mild Risk." Review revealed the Behavioral Health Assessment Team was consulted related to the patient's admission to the Behavioral Health Unit. Review failed to reveal any Suicide Risk Assessment Scoring performed by the Behavioral Health's Assessment Team.

Interview with Behavioral Health Unit management staff on 03/29/2012 at 1515 revealed a patient who presents with intentional harm to themselves should be screened for suicide risk by the Emergency Department (ED) staff and then by the Behavioral Health Assessment Team if found to be at risk for Suicide from the ED risk assessment. Record review during the interview revealed Patient #40 should be considered a high suicide risk due to his intentional self-harm by cutting his arm. Interview revealed the Behavioral Health Assessment Team should have completed a suicide risk assessment which included a risk score during the patient's admission screening process while in the Emergency Department. Interview failed to reveal any documented evidence of any suicide risk scoring being completed by the Behavioral Health Assessment Team staff prior to the patient's admission to the Behavioral Health Unit at 0300 (12 hours prior to the record review). Interview failed to reveal any suicide risk scoring being competed from the time of admission until the record review during the interview. Interview revealed staff failed to follow facility policy by failing to complete a suicide risk assessment for Patient #40, who had demonstrated acts of a suicide attempt through self-harm.

B. Review on 03/28/2012 of facility policy "Observation, Levels of Patient" revised 11/2011 revealed "II. Policy: It is the policy of the Psychiatric Unit provide appropriate levels of supervision for patients based on patient's behavior, diagnosis, and admission status and physician orders. III. Definitions...2. Special Precautions: a. Frequent Checks: Patient is observed every 15 minutes...IV. Procedure: 1. In an emergency situation, the RN (Registered Nurse) in charge, in collaboration with other staff, may place a patient on Special Precautions..."

Closed record review for Patient #47 revealed a 39 year old admitted 10/21/2010 as in involuntary commitment for suicidal ideations with a plan. Review revealed nursing documentation dated 10/22/2010 at 1030 which revealed "Pt (patient) seen by Dr. (name of physician). Pt had left unit (escaped) via backdoor of unit. Noted on camera @ 0910. Propped door open (symbol for 'with') shoe. Pt caught door before it clicked closed (symbol for 'after') staff left. Brought back to unit by outpatient registration staff @ 0943. Admitted to leaving unit (sneaking out) said he was gone for an hour and said that he ran into woods (area surrounding hospital is commercial). Pt calm/cooperative. Belongings checked (ordered by Dr. [name of physician]). Pt restricted to unit/freq(ent) (symbol for 'checks') began...". Review of documentation revealed the patient was placed on the special precautions "frequent checks" through 10/23/2012 at 1100.

Interview with Behavioral Health Unit management staff on 03/29/2012 at 1530 revealed the standard observation level for all patients in the Psychiatric Unit is "Watchful Awareness (WA)" which means every patient is accounted for every hour. Interview revealed Patient #47 was on WA observation from the time of admission on 10/21/2012 until he eloped from the unit and was returned on 10/22/2012 at approximately 0943. Interview revealed once the patient returned he was placed on a higher level observation "Frequent Checks" by the RN. Interview revealed the RN can initiate the higher level supervision, however, must call for a physician's order to continue the more strict observation status. Record review during the interview revealed there was no documented evidence in the patient's record of a physician's order being obtained for the higher observation level for Patient #47. Further record review during the interview revealed Patient #47's observation level was decreased from frequent checks to watchful awareness on 10/23/2012 at 1100. Interview revealed observation levels can only be decreased by a physician's order. Record review during the interview revealed there was no physician's order obtained to decrease the patient's observation level status. Interview revealed staff failed to follow policy by failing to obtain a physician's order for a higher lever observation level and further failed to follow policy by failing to obtain a physician's order to decrease the supervision level for Patient #47.

C. Review on 03/28/2012 a facility psychiatric unit booklet "Patient's instructions - Rules for Living: A guide to daily living for Behavioral Services Psychiatric Unit" revised 01/11 revealed "(page 14) Groups and Classes - 1. A large part of your treatment will involve going to groups and classes to learn more about issues that affect you and your treatment goals. It is vital that you get involved in these groups to ensure that you get the most out of your stay here."

1. Open record review for Patient #38 revealed a 26 year old admitted 03/15/2012 for Schizoeffective disorder. Review revealed the patient had daily scheduled groups/classes. Review of the form "Psychiatric Unit Daily Group Attendance/Education Sheet" revealed "Key: *Did not attend - requires comment...". Review revealed on the following dates/times the patient was scheduled to attend a group/class and there was no indication the patient did or did not attend and comment as to why the patient did not attend: 03/28/2012 at 1415 and 2200, 03/27/2012 at 2200, 03/26/2012 at 1530 and 2200, 03/25/2012 at 1030 and 2200, 03/24/2012 at 1300, 2000 and 2200, 03/23/2012 at 2200, 03/22/2012 at 2200, 03/21/2012 at 1415 and 2200, 03/20/2012 at 2200, 03/19/2012 at 1415, 1530 and 2200, 03/18/2012 at 1315, 1930, 2000 and 2200, 03/17/2012 at 1300, 2000 and 2200. Review revealed the patient had 67 groups/classes scheduled from 03/17/2012 through 03/28/2012 and declined or had no evidence of attendance for 45 of the scheduled groups/classes. Review revealed Patient #38 attended 33% of the scheduled groups/classes from 03/17/2012 through 03/28/2012 (or 22 of 67 groups/classes scheduled).

2. Closed record review for Patient #46 revealed a 52 year old admitted 11/15/2010 for substance abuse detox. Review revealed the patient had daily scheduled groups/classes. Review of the form "Psychiatric Unit Daily Group Attendance/Education Sheet" revealed "Key: *Did not attend - requires comment...". Review revealed on the following dates/times the patient was scheduled to attend a group/class and there was no indication the patient did or did not attend and comment as to why the patient did not attend: 11/20/2010 at 1300, 11/19/2010 at 2200, 11/18/2010 at 1015, 11/18/2010 at 1415, 11/18/2010 at 2200, 11/17/2010 at 2000, 11/18/2010 at 2200, and 11/16/2010 at 2200. Review revealed the patient had 26 groups/classes scheduled from 11/15/2010 through 11/20/2010, when the patient was discharged, and declined or had no evidence of attendance for 15 of the scheduled groups/classes. Review revealed Patient #46 attended 42% of the scheduled groups/classes from 11/15/2010 through 11/20/2010(or 11 of 26 groups/classes scheduled).

3. Closed record review for Patient #47 revealed a 39 year old admitted 10/21/2010 as an involuntary commitment for suicidal ideations. Review revealed the patient was discharged 10/26/2010. Review revealed the patient had daily scheduled groups/classes. Review of the form "Psychiatric Unit Daily Group Attendance/Education Sheet" revealed "Key: *Did not attend - requires comment...". Review of Group Attendance records from 10/22/2010 through 10/25/2010 revealed on the following dates/times the patient was scheduled to attend a group/class and there was no indication the patient did or did not attend and comment as to why the patient did not attend: 10/25/2010 at 2200, 10/24/2010 at 2200, 10/23/2010 at 0915, 10/23/2010 at 2200, and 10/22/2010 at 2200. Review revealed the patient had 22 groups/classes scheduled from 10/22/2010 through 10/25/2010 and declined or had no evidence of attendance for 5 of the scheduled groups/classes. Review revealed Patient #47 attended 77% of the scheduled groups/classes from 10/22/2010 through 10/25/2010 (or 17 of 22 groups/classes scheduled).

4. Closed record review for Patient #45 revealed a 49 year old admitted 03/21/2010 for major depressive disorder. Review revealed the patient was discharged 03/23/2010/2010. Review revealed the patient had daily scheduled groups/classes. Review of the form "Psychiatric Unit Daily Group Attendance/Education Sheet" revealed "Key: *Did not attend - requires comment...". Review of Group Attendance records from 03/22/2010 through 03/23/2010 revealed on the following dates/times the patient was scheduled to attend a group/class and there was no indication the patient did or did not attend and comment as to why the patient did not attend: 03/23/2010 at 0915, 03/22/2010 at 1530, 03/22/2010 at 2200. Review revealed the patient had 20 groups/classes scheduled from 03/22/2010 through 03/23/2010 and declined or had no evidence of attendance for 7 of the scheduled groups/classes. Review revealed Patient #45 attended 65% of the scheduled groups/classes from 03/22/2010 through 03/23/2010 (or 13 of 20 groups/classes scheduled).

Interview on 03/29/2012 at 1520 with behavioral health unit Registered Nurse (RN) staff revealed the "Psychiatric Unit Daily Group Attendance/Education Sheet" is utilized to document patient attendance in the therapeutic groups/classes offered as part of the patient's treatment regimen. Interview revealed patients may decline to attend the groups or "sometimes we just don't have enough staff to have the groups". Interview revealed if a patient does not attend a group there should be reason documented as to why the patient did not attend. Interview revealed staff failed to follow facility policy by failing to document a reason the patient did not attend the therapeutic groups/classes.

Based on review of facility policies and procedures, medical records and staff interviews staff failed to ensure interdisciplinary patient care plans (treatment plans) were developed per facility policy for 3 of 4 behavioral health records reviewed (#38, #46, #47).

Findings included:

Review on 03/28/2012 of facility policy "Interdisciplinary Treatment Planning" revised 05/2009 revealed "Procedure: ...2...a Treatment Plan will be initiated for each patient within 72 hours of admission...4. Treatment Planning meetings are interdisciplinary. Staff members who participate include, but are not limited to, the attending physician, AD/Supervisor, Counselors, Charge RN, nursing staff, Therapeutic Recreation Specialist, social workers, Utilization Review...10. Weekly meetings will occur to allow the team to review, update, and revise the plan as necessary."

1. Open record review on 03/29/2012 for Patient #38 revealed a 26 year old female admitted to the hospital's behavioral unit on 03/15/2012 for schizoeffective disorder. Review revealed an interdisciplinary treatment plan meeting dated 03/15/2012. Review failed to reveal any further interdisciplinary review for the patient's treatment plan since admission (14 days).

Interview with behavioral unit management staff on 03/29/2012 at 1500 revealed an interdisciplinary treatment plan review should occur every seven days. Interview revealed there was no documented evidence Patient #38 had a treatment team review of the treatment plan since 03/15/2012, the patient's date of admission. Interview revealed staff failed to follow facility policy by failing to provide a treatment plan review every 7 days.

2. Closed record review on 03/28/2012 for Patient #46 revealed a 52 year old admitted to the hospital's behavioral unit 11/15/2010 for substance abuse detox. Review revealed a treatment plan review dated 11/15/2010. Review failed to reveal documented evidence the physician for Patient #46 was involved in the treatment plan review. Review revealed the patient was discharged from the facility 11/20/2010. Review revealed the only treatment plan team meeting was on 11/15/2010.

Interview with behavioral unit management staff on 03/29/2012 at 1545 revealed the treatment planning interdisciplinary team includes the physician. Interview revealed the treatment plan team meeting dated 11/15/2010 for Patient #46 did not include any evidence the physician was involved in the meeting. Interview failed to reveal any documented evidence the physician was involved in the patient's treatment planning during the stay on the behavioral health unit from 11/15/2010 through 11/20/2010.

3. Closed record review on 03/28/2012 for Patient #47 revealed a 39 year old admitted to the hospital's behavioral unit 10/21/2010 as an involuntary commitment for suicidal ideations. Review revealed a treatment plan review dated 10/21/10. Review failed to reveal documented evidence any counselor, therapeutic recreation specialist, or social worker was involved in the treatment plan review. Review revealed the patient was discharged from the facility 10/26/2010. Review revealed the only treatment plan team meeting was on 10/21/2010.

Interview with behavioral unit management staff on 03/29/2012 at 1545 revealed the treatment planning interdisciplinary team includes a counselor, therapeutic recreation specialist, and social worker. Interview revealed the treatment plan team meeting dated 10/21/2010 for Patient #47 did not include any evidence any counselor, therapeutic recreation specialist, or social worker was involved in the meeting. Interview failed to reveal any documented evidence any counselor, therapeutic recreation specialist, or social worker was involved in the patient's treatment planning during the stay on the behavioral health unit from 10/21/2010 through 10/26/2010.

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