HospitalInspections.org

Based on review of facility policies and procedures, medical records (MR), facility investigation documentation and interviews it was determined the facility failed to ensure a safe environment for patients at risk for suicide.

Refer to A 144 for findings.

Based on review of facility policies and procedures, medical records (MR), facility investigation documentation and interviews it was determined the facility failed to ensure:

1. Psychiatric patients on the Mental Health Crisis Unit (MHCU) were observed every 15 minutes as ordered, and directed per policy.
2. A patient with a Moderate Suicide Risk was placed on Continuous Visual Observation as directed per policy.
3. A patient with a High Suicide Risk was placed on 1:1 (one to one) observation as directed per policy.
4. Documentation on the Patient Observation forms was complete and accurate.
5. The Registered Nurse (RN) monitored the Q (every) 15 minute observations by the Patient Care Assistant (PCA) as directed per policy.
6. Doors to patient rooms were left open at least 12 inches at bedtime as directed per policy.

The deficient practice affected 3 of 3 MHCU records reviewed including Patient Identifier (PI) # 1, PI # 2 , PI # 3 and had the potential to affect all patients admitted for psychiatric care.

Findings include:

Policy / Procedure Title: Observation of the Psychiatric Patient
Date Reviewed: 9/2018

Purpose
It is the policy of the Psychiatric Unit that monitoring is instituted to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member who becomes aware of this.

Policy
All patients, when admitted to the Psychiatric Unit will be automatically placed on 15 minute observation checks, by a staff member. This will be considered routine observation and will continue until discharge.

Procedure
Constant visual or 1:1 observation can be done for the following reasons: agitation/assault...suicide precautions and withdrawal. The Psychiatrist will be contacted to give a specific order for the level of monitoring. Any discontinuation of monitoring or lessening or increasing of the level of monitoring must be by Psychiatrist's order with documentation for rationale.

Policy / Procedure Title: Suicidal Patient
Date Reviewed: 9/2018

Purpose
The purpose of this policy is to guide the patient care staff in identification of individuals at risk for suicide and to implement necessary actions toward preventing self harm while under the care of or following discharge from the organization.

Policy
1. Suicide precautions may be ordered by the patient's physician or may be initiated by the nurse with a physician's order obtained as soon as possible.
2. All patients...will be screened for suicide risks. An initial SAFE-T Protocol must be performed on each patient and further assessments if indicated...
3. A patient admitted with a status for serious self injurious behavior (or risk of) will be placed on the appropriate suicide precautions...

Columbia Suicide Severity Rating Scale (C-SSRS): includes the following components.
1. Safe-T Protocol: This protocol should be performed on all patients...
2. Long Protocol: The long protocol should be completed if "yes" answered to any question 1-5 of the Safe-T protocol.
3. Frequent Screener Protocol: This protocol is the reassessment that should be completed every shift.

Observation Level Definitions:
Routine Observation - Low Risk: The patient will be checked every 15 minutes by a staff member. Document, as appropriate, in the medical record.

Constant Visual Observation - Moderate Risk: Constant Visual Observation is the second level of observation. It includes all of the components of routine observation. Additionally, the patient is either observed in a video monitored room by a designated observer or observed at all times by the naked eye. The RN assigned to this patient is responsible to ensure that Constant Visual Observation is in place. The RN documents each shift the continuation of Constant Visual Observation.

1:1 Observation - High Risk: 1:1 observation is the third level of observation...a staff member is assigned...to be physically present with this patient at all times...


Policy / Procedure Title: Use of Patient Video Monitoring
Date Reviewed: 9/2018

Policy
Upon admission to the program, patients in the Psychiatric unit will sign consent that they have been educated about and informed of the video monitoring system utilized in the program.

Procedure
A. In-Room Video Monitoring
...3. In-room video monitoring will only be utilized to ensure patient safety...

Policy / Procedure Title: Nursing Rounds
Date Reviewed: 9/2018

Purpose
To ensure a safe environment.

Policy
a. The Nurse is responsible for making rounds on their assigned patients in order to account for all patients' whereabouts and ensure a safe environment.
b. The nurse monitors the q (every) 15 minute observations by the patient care assistant.

Procedure
A. The Patient Care Assistant (PCA) assigned to the patient will complete his/her safety rounds every 15 minutes during their shift. If there is no Patient Care Assistant assigned, the RN will complete safety rounds on each patient every 15 minutes during the shift.
B. Once patients are prepared for bed time, the doors to their rooms are left open at least 12 inches...so as to:
1. Allow staff to readily hear any noise coming from the room.
2. Allow staff to enter the room for night rounds without waking the patients...
C. Flashlights are used during the night rounds...
D. The PCA/RN must enter the room to observe the presence and safety of the patient.

1. PI # 1 was admitted to the MHCU on 2/21/2020 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the MR revealed PI # 1 presented to the Emergency Department (ED) on 2/21/20 at 2:25 PM with complaints of depression, anxiety, audio/visual hallucinations and suicidal thoughts. PI # one's mother informed the ED nurse the patient had "gone outside the house stating he/she was going to get a yellow rope and telling me to leave him/her alone for about 10-15 minutes." The ED documentation continued "with mother feeling that he/she was going to attempt hanging."

Review of the MR order summary revealed a medical order dated 2/21/20 at 2:27 PM by the ED physician for CVO (continuous visual observation).

Review of the suicide risk assessment dated 2/21/20 at 2:40 PM revealed PI # 1 had attempted suicide in July 2019 by cutting his/her arms deeply and long scars were noted to both arms. The suicide risk was documented as Moderate Suicide Risk.

PI # 1 was admitted to the psychiatric MHCU on 2/21/20 with hand written verbal admission orders obtained at 4:25 PM which included Agitation Protocol and Routine Orders. There were no orders included for the observation level and frequency nor for safety precautions.

Review of the MR order summary revealed nursing orders dated 2/21/20 at 5:26 PM for assault precautions, suicide precautions, and routine observation every 15 minutes.

Review of the RN admission assessment dated 2/21/20 at 5:38 PM revealed PI # 1 had a history of depression, anxiety, past psychiatric treatment with last hospitalization in January 2020 at MHCU and a suicide attempt in July 2019.

Further review of the RN admission assessment dated 2/21/20 revealed PI # 1 rated his/her depression as 10 (1-10 scale), and answered "Yes" to the following C-SSRS Safe-T suicide assessment questions:
Thoughts to harm yourself or others in last 6 months;
Past month, wished to be dead or go to sleep & not wake up;
Past month, actually had thoughts of killing yourself;
Past month, have been thinking of how you might do this;
Lifetime, have you started / prepared to end life.

Suicide Risk Score - Moderate Suicide Risk.

Further review of the RN admission assessment dated 2/21/20 at 5:38 PM revealed:
Paranoid/Hostility: High Risk
Impulsivity: Moderate Risk
Agitation: Moderate Risk
Total Risk Score: 4
9 or more - 1:1 observation
3-8 constant visual
0-2 routine observation

There was no documentation the psychiatrist was notified of PI # 1's risk assessment completed on 2/21/20 at 5:38 PM nor of the risk scores which indicated the need for constant visual observation. Further, there was no documentation in the MR of the rationale, as directed in policy, for decreasing the observation level from CVO to routine every 15 minute observation.

Review of the Treatment Plan dated 2/21/20 at 4:50 PM revealed Problem Number 1 was Suicide Ideation/Plan/Attempt as evidenced by hopelessness, helplessness related to hx of depression and Schizophrenia.
Long-term goal: not demonstrate or verbalize active suicide plan for a period of 7 days.
Short-term goal: will alert staff if having active suicidal thoughts/ideation and verbalize 2 alternative way(s) of coping. Will remain safe with no attempts at suicide during stay at this hospital.
Nursing Intervention: Assess patient through 1:1 contact for suicidal ideation and ask direct questions related to suicidal thoughts or mood. Encourage patient to contract for safety every shift and prn (as needed)...The patient will be visualized by staff when in bed sleeping to ensure presence of safety.
There was no documentation of the patient's Suicide Risk Score or ordered observation level on the treatment plan.

Review of the Frequent Screener documentation revealed the following questions:
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts w/some (with some) intention to act on them?
Have you started to work out / worked out a plan?
Have you ever done / started / prepared to end your life?

The above questions were answered "no" with Suicide Risk Level as "No Risk" at the following times:
2/21/20 at 1945 (7:45 PM)
2/22/20 at 0911 (9:11 AM)
2/22/20 at 1940 ( 7:40 PM)
2/23/20 at 1002 (10:02 AM)
2/24/20 at 0810 (8:10 AM)
2/24/20 at 2209 (10:09 PM)
2/25/20 at 0930 (9:30 AM) - only 2 of the 5 questions were documented at this time.
2/26/20 at 0111 (1:11 AM)

Review of the Q 15 minute observation sheets from 2/21/20 at 5:00 PM to 2/26/20 revealed the area at the top of each form which indicated the Level of Observation, Frequency of Observation, and Type of Precautions in Place, were left blank.

Review of the nursing note dated 2/26/20 revealed at 5:45 AM the nurse "went to the patients room for vital signs and patient was unresponsive. Called for help and charge nurse came in and shirt found around the patient's neck. Shirt removed from neck. No pulse or respiratory effort and Code Blue paged. CPR was started."

Review of the Code Blue documentation revealed the resuscitative efforts were unsuccessful and PI # 1 was pronounced deceased at 6:09 AM. The responding ED physician documented the following note: "I responded to the code blue and found patient unresponsive, cyanotic, pulseless and in rigor...Code called at 0609."

Review of the facility documented Incident Timeline dated 2/25/20 10:00 PM to 2/26/20 8:00 AM of the video recording revealed the following:

10:39 PM - (EI # 3) PCP looks in on the patient.

1:37 AM - Patient gets out of bed and opens the door to his/her room. (EI # 3, EI # 4 RN), and the security guard are standing outside of the door next to his/her room, patient asked them what time it is and then closed his/her door.

1:38 AM - Patient returns to bed and reaches for an article of clothing.

1:39 AM - Patient takes a long sleeve shirt and rolls it up and ties it around his/her neck.

1:40 AM - Patient lays back on the bed facing away from the camera and remains still.

1:46 AM - Patient rolls over on his/her back and his/her right arm falls off the bed and there is no further movement.

4:48 AM - (EI # 5, RN Charge Nurse) opens the door and looks in on the patient and closes the door.

5:17 AM - (EI # 6, RN) opens the door and looks in on the patient for several seconds. (EI # 6) leaves, but returns shortly thereafter to again open the door and look in on the patient. He/she closes the door and leaves.

5:40 AM - (EI # 4) comes into the room to take vital signs. He/she stops and turns the light on and realizes that something is wrong. He/she leaves the room and returns with (EI # 5). (EI # 5) notices the shirt around the patient's neck and proceeds to remove it.

5:42 AM - Code Blue is called, security, respiratory therapy, house supervisor, and other personnel show up to administer the code.

6:09 AM - Patient is pronounced deceased.

6: 32 AM - Patient is prepared for viewing.

6:36 AM - Patient is moved to our ICU for family viewing.

Further review of the Q 15 minute observation sheet dated 2/26/20 revealed at 1:45 AM to 5:30 AM PI # 1 was in Room; In bed, eyes closed, breathing and Quiet documented by EI # 5, RN Charge Nurse.

A phone interview was conducted on 4/6/20 at 9:45 AM with EI # 5 RN MHCU night shift. EI # 5 verified Q 15 minute checks on PI # 1 on 2/26/20 from 2:00 AM to 5:30 AM were done by looking at the camera and not going into the room. EI # 5 stated the process now is to use a flashlight and go into each room to make sure the patient is breathing.

An interview conducted on 4/8/2020 at 12:35 PM with EI # 1, Director of Nursing, confirmed the above timeline documentation was taken from reviewing the video recording in PI # 1's room and the video recording of the hallway outside. EI # 1 further confirmed the video only records when there is movement detected. EI # 1 confirmed no one entered PI # 1's room from 10:39 PM the evening of 2/25/20 until PI # 1 opened the door at 1:37 AM on 2/26/20 stating it was discovered during their investigation the 15 minute checks were not performed by actually going into the room, but by checking the video monitor.

2. PI # 2 was admitted to the psychiatric MHCU on 2/19/20 with diagnoses including Depressive Disorder and Suicidal Ideation.

Review of the MR revealed PI # 2 presented to the ED on 2/19/20 at 12:55 PM with depression and stated "I have nothing to live for anymore. I am alone all the time. I think about leaving this world all the time...always thinking of a way but never wants to act on them".

Review of the C-SSRS dated 2/19/20 at 1:10 PM in the ED revealed: "thoughts of hanging in the past month, suicide by cop and jumping on a knife, daily."

Suicide Risk Score: High Suicide Risk

Review of the MR order summary revealed a medical order dated 2/19/20 at 5:46 PM for continuous visual observation.

Review of the hand written verbal admission orders dated 2/19/20 at 9:30 PM revealed "Routine Standing Orders" and "CIWA (Clinical Institute Withdrawal Assessment) protocol." There were no orders for the observation level and frequency nor for safety precautions.

Further review of the MR order summary revealed nursing orders dated 2/19/20 at 9:36 PM for suicide precautions, and routine observation every 15 minutes.

There was no documentation the psychiatrist was notified of the patient's High Suicide Risk score which indicated the need for 1:1 observation. Further, there was no documentation in the MR of the rationale, as directed in policy, for decreasing the observation level from CVO to routine every 15 minute observation.

Review of the RN admission assessment dated 2/20/20 at 12:54 AM revealed PI # 2 had a history of depression, anxiety, substance withdrawal, and past psychiatric treatment in the MHCU.

Further review of the RN admission assessment dated 2/20/20 revealed PI # 2 rated his/her depression as 10 and answered "yes" to the following C-SSRS Safe-T assessment questions:
Past month, wished to be dead or go to sleep & not wake up;
Past month, actually had thoughts of killing yourself;
Past month, have been thinking of how you might do this;
Past month, had thoughts with some intention to act;
Lifetime, have you started / prepared to end life;
Was it within the past 3 months?

Suicide Risk Level: High Suicide Risk.

Review of the Treatment Plan dated 2/19/20 at 9:45 PM revealed Problem Number 1 was Suicide Ideation/Plan/Attempt as evidenced by isolative, hopelessness and helplessness.
Nursing Intervention: Assess patient through 1:1 contact for suicidal ideation and ask direct questions related to suicidal thoughts or mood. Encourage patient to contract for safety every shift. Perform environmental rounds/safety checks per precaution level every 15 minutes. Nursing will complete a Suicide Risk Assessment every shift and report to Psychiatrist scores of greater than 16.

There was no documentation of the patient's Suicide Risk Score or ordered observation level on the treatment plan.

Review of the MR revealed the next suicide assessment was completed on 2/21/20 at 7:30 PM, which was 43 hours and 42 minutes later, and not every shift as documented on PI # 2's treatment plan.

Review of the Q 15 minute observation sheets dated 2/19/20 to 2/25/20 revealed the area at the top of each form which indicated the Level of Observation, Frequency of Observation, and Type of Precautions in Place, were left blank.

Review of the physician assessment/plan dated 2/20/20 and dictated at 10:01 AM revealed PI # 2 had 3 prior psychiatric hospitalizations and no suicide attempts, initially presented to the ED intoxicated...verbalizing suicidal ideations...after..sober up...continued to verbalize suicidal ideations with a plan to stab himself to the heart...reports feelings of hopelessness...feels like he/she is a burden and is tired of his/her life...on exam (examination)...continues to report suicidal ideations as well as depressed mood and neurovegatative symptoms of depression.

Review of the nurses note dated 2/21/20 at 8:30 AM revealed "pt (patient) isolated to room...anxiety rated at 7 and depression 9/10 ( 9 out of 10)...when asked about SI (suicidal ideations)..states "not today" then stated "not yet today"...

There was no documentation a suicide risk assessment or screening was performed.

Review of the physician's progress note dated 2/21/20 and dictated at 1:09 PM revealed PI # 2 "continues to report passive suicidal ideations."

Review of the Frequent Screener documentation in the MR revealed the following questions:
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts w/some (with some) intention to act on them?
Have you started to work out / worked out a plan?
Have you ever done / started / prepared to end your life?

The above questions were answered "no" with Suicide Risk Level as "No Risk" at the following times:
2/21/20 at 1930 (7:30 PM)
2/22/20 at 1925 (7:25 PM)
2/23/20 at 1955 (7:55 PM)
2/24/20 at 1201 (12:01 PM)
2/25/20 at 1030 (10:30 AM)

There was no documentation the staff completed a Suicide Risk Assessment every shift according to PI # 2's treatment plan and there was no documentation the patient was placed on 1:1 nor continuous visual observation as directed per the facility policy for suicidal patients.

A phone interview conducted on 4/8/2020 at 12:45 PM with EI # 1, Director of Nursing, confirmed the suicide assessment was not completed, the observation sheets failed to be completed with the observation level and safety precautions, and the policy for suicidal patients observation level was not followed.



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3. PI # 3 was admitted to the facility on 2/25/2020 with a diagnosis of Unspecified Depressive Disorder.

PI # 3 arrived to the MHCO on 2/25/2020 at 9:00 PM.

Review of the Observation Form dated 2/25/2020 revealed the Observation/Frequency was LOS (line of sight) and no documentation of the Type of Precautions.

Further review of the Observation Form dated 2/25/2020 revealed no documentation of every 15 minute observations between 9:15 PM to 11:45 PM.

Review of the Observation Forms dated 2/26/2020, 2/27/2020, 2/28/2020, 3/2/2020 and 3/3/2020 revealed no documentation of Observation/Frequency or Type of Precautions.

A written question was submitted to EI # 1 on 4/2/2020 asking if there was documentation of every 15 minute observation on 2/25/2020 between 9:15 PM to 11:45 PM. A written response was received from EI # 1 on 4/2/2020 at 4:49 PM stating, "I have reviewed the chart and there is not an observation form for those dates".

Based on review of facility policies and procedures, medical records (MR), and interviews it was determined the facility failed to ensure:

1. Patient observations were completed and documented every 15 minutes according to the facility policy.
2. Patients were assessed for suicide risk and precautions were implemented as indicated in facility policies.

Refer to A 392 for findings.

Based on review of facility policies and procedures, medical records (MR), and interviews it was determined the facility failed to ensure:

1. Psychiatric patients on the Mental Health Crisis Unit (MHCU) were observed every 15 minutes as ordered, and directed per policy.
2. A patient with a Moderate Suicide Risk was placed on Continuous Visual Observation as directed per policy.
3. A patient with a High Suicide Risk was placed on 1:1 (one to one) observation as directed per policy.
4. Documentation on the Patient Observation forms was complete and accurate.
5. The Registered Nurse (RN) monitored the Q (every) 15 minute observations by the Patient Care Assistant (PCA) as directed per policy.


These deficient practices affected 3 of 3 MHCU records reviewed including Patient Identifier (PI) # 1, PI # 2 , PI # 3 and had the potential to affect all patients admitted for psychiatric care.

Findings include:

Policy / Procedure Title: Observation of the Psychiatric Patient
Date Reviewed: 9/2018

Purpose
It is the policy of the Psychiatric Unit that monitoring is instituted to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member who becomes aware of this.

Policy
All patients, when admitted to the Psychiatric Unit will be automatically placed on 15 minute observation checks, by a staff member. This will be considered routine observation and will continue until discharge.

Procedure
Constant visual or 1:1 observation can be done for the following reasons: agitation/assault...suicide precautions and withdrawal. The Psychiatrist will be contacted to give a specific order for the level of monitoring. Any discontinuation of monitoring or lessening or increasing of the level of monitoring must be by Psychiatrist's order with documentation for rationale.

Policy / Procedure Title: Suicidal Patient
Date Reviewed: 9/2018

Purpose
The purpose of this policy is to guide the patient care staff in identification of individuals at risk for suicide and to implement necessary actions toward preventing self harm while under the care of or following discharge from the organization.

Policy
1. Suicide precautions may be ordered by the patient's physician or may be initiated by the nurse with a physician's order obtained as soon as possible.
2. All patients...will be screened for suicide risks. An initial SAFE-T Protocol must be performed on each patient and further assessments if indicated...
3. A patient admitted with a status for serious self injurious behavior (or risk of) will be placed on the appropriate suicide precautions...

Columbia Suicide Severity Rating Scale (C-SSRS): includes the following components.
1. Safe-T Protocol: This protocol should be performed on all patients...
2. Long Protocol: The long protocol should be completed if "yes" answered to any question 1-5 of the Safe-T protocol.
3. Frequent Screener Protocol: This protocol is the reassessment that should be completed every shift.

Observation Level Definitions:
Routine Observation - Low Risk: The patient will be checked every 15 minutes by a staff member. Document, as appropriate, in the medical record.

Constant Visual Observation - Moderate Risk: Constant Visual Observation is the second level of observation. It includes all of the components of routine observation. Additionally, the patient is either observed in a video monitored room by a designated observer or observed at all times by the naked eye. The RN assigned to this patient is responsible to ensure that Constant Visual Observation is in place. The RN documents each shift the continuation of Constant Visual Observation.

1:1 Observation - High Risk: 1:1 observation is the third level of observation...a staff member is assigned...to be physically present with this patient at all times...

Policy / Procedure Title: Use of Patient Video Monitoring
Date Reviewed: 9/2018

Policy
Upon admission to the program, patients in the Psychiatric unit will sign consent that they have been educated about and informed of the video monitoring system utilized in the program.

Procedure
A. In-Room Video Monitoring
...3. In-room video monitoring will only be utilized to ensure patient safety...

Policy / Procedure Title: Nursing Rounds
Date Reviewed: 9/2018

Purpose
To ensure a safe environment.

Policy
a. The Nurse is responsible for making rounds on their assigned patients in order to account for all patients' whereabouts and ensure a safe environment.
b. The nurse monitors the q (every) 15 minute observations by the patient care assistant.

Procedure
A. The Patient Care Assistant (PCA) assigned to the patient will complete his/her safety rounds every 15 minutes during their shift. If there is no Patient Care Assistant assigned, the RN will complete safety rounds on each patient every 15 minutes during the shift.
B. Once patients are prepared for bed time, the doors to their rooms are left open at least 12 inches...so as to:
1. Allow staff to readily hear any noise coming from the room.
2. Allow staff to enter the room for night rounds without waking the patients...
C. Flashlights are used during the night rounds...
D. The PCA/RN must enter the room to observe the presence and safety of the patient.

1. PI # 1 was admitted to the MHCU on 2/21/2020 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the MR revealed PI # 1 presented to the Emergency Department (ED) on 2/21/20 at 2:25 PM with complaints of depression, anxiety, audio/visual hallucinations and suicidal thoughts. PI # one's mother informed the ED nurse the patient had "gone outside the house stating he/she was going to get a yellow rope and telling me to leave him/her alone for about 10-15 minutes." The ED documentation continued "with mother feeling that he/she was going to attempt hanging."

Review of the MR order summary revealed a medical order dated 2/21/20 at 2:27 PM by the ED physician for CVO (continuous visual observation).

Review of the suicide risk assessment dated 2/21/20 at 2:40 PM revealed PI # 1 had attempted suicide in July 2019 by cutting his/her arms deeply and long scars were noted to both arms. The suicide risk was documented as Moderate Suicide Risk.

PI # 1 was admitted to the psychiatric MHCU on 2/21/20 with hand written verbal admission orders obtained at 4:25 PM which included Agitation Protocol and Routine Orders. There were no orders included for the observation level and frequency nor for safety precautions.

Review of the MR order summary revealed nursing orders dated 2/21/20 at 5:26 PM for assault precautions, suicide precautions, and routine observation every 15 minutes.

Review of the RN admission assessment dated 2/21/20 at 5:38 PM revealed PI # 1 had a history of depression, anxiety, past psychiatric treatment with last hospitalization in January 2020 at MHCU and a suicide attempt in July 2019.

Further review of the RN admission assessment dated 2/21/20 revealed PI # 1 rated his/her depression as 10 (1-10 scale), and answered "Yes" to the following C-SSRS Safe-T suicide assessment questions:
Thoughts to harm yourself or others in last 6 months;
Past month, wished to be dead or go to sleep & not wake up;
Past month, actually had thoughts of killing yourself;
Past month, have been thinking of how you might do this;
Lifetime, have you started / prepared to end life.

Suicide Risk Score - Moderate Suicide Risk.

Further review of the RN admission assessment dated 2/21/20 at 5:38 PM revealed:
Paranoid/Hostility: High Risk
Impulsivity: Moderate Risk
Agitation: Moderate Risk
Total Risk Score: 4
9 or more - 1:1 observation
3-8 constant visual
0-2 routine observation

There was no documentation the psychiatrist was notified of PI # 1's risk assessment completed on 2/21/20 at 5:38 PM nor of the risk scores which indicated the need for constant visual observation. Further, there was no documentation in the MR of the rationale, as directed in policy, for decreasing the observation level from CVO to routine every 15 minute observation.

Review of the Treatment Plan dated 2/21/20 at 4:50 PM revealed Problem Number 1 was Suicide Ideation/Plan/Attempt as evidenced by hopelessness, helplessness related to hx of depression and Schizophrenia.
Long-term goal: not demonstrate or verbalize active suicide plan for a period of 7 days.
Short-term goal: will alert staff if having active suicidal thoughts/ideation and verbalize 2 alternative way(s) of coping. Will remain safe with no attempts at suicide during stay at this hospital.
Nursing Intervention: Assess patient through 1:1 contact for suicidal ideation and ask direct questions related to suicidal thoughts or mood. Encourage patient to contract for safety every shift and prn (as needed)...The patient will be visualized by staff when in bed sleeping to ensure presence of safety.
There was no documentation of the patient's Suicide Risk Score or ordered observation level on the treatment plan.

Review of the Frequent Screener documentation revealed the following questions:
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts w/some (with some) intention to act on them?
Have you started to work out / worked out a plan?
Have you ever done / started / prepared to end your life?

The above questions were answered "no" with Suicide Risk Level as "No Risk" at the following times:
2/21/20 at 1945 (7:45 PM)
2/22/20 at 0911 (9:11 AM)
2/22/20 at 1940 ( 7:40 PM)
2/23/20 at 1002 (10:02 AM)
2/24/20 at 0810 (8:10 AM)
2/24/20 at 2209 (10:09 PM)
2/25/20 at 0930 (9:30 AM) - only 2 of the 5 questions were documented at this time.
2/26/20 at 0111 (1:11 AM)

Review of the Q 15 minute observation sheets from 2/21/20 at 5:00 PM to 2/26/20 revealed the area at the top of each form which indicated the Level of Observation, Frequency of Observation, and Type of Precautions in Place, were left blank.

Review of the nursing note dated 2/26/20 revealed at 5:45 AM the nurse "went to the patients room for vital signs and patient was unresponsive. Called for help and charge nurse came in and shirt found around the patient's neck. Shirt removed from neck. No pulse or respiratory effort and Code Blue paged. CPR was started."

Review of the Code Blue documentation revealed the resuscitative efforts were unsuccessful and PI # 1 was pronounced deceased at 6:09 AM. The responding ED physician documented the following note: "I responded to the code blue and found patient unresponsive, cyanotic, pulseless and in rigor...Code called at 0609."

Further review of the Q 15 minute observation sheet dated 2/26/20 revealed at 1:45 AM to 5:30 AM PI # 1 was in Room; In bed, eyes closed, breathing and Quiet documented by EI # 5, RN Charge Nurse.

A phone interview was conducted on 4/6/20 at 9:45 AM with EI # 5 RN MHCU night shift. EI # 5 verified Q 15 minute checks on PI # 1 on 2/26/20 from 2:00 AM to 5:30 AM were done by looking at the camera and not going into the room. EI # 5 stated the process now is to use a flashlight and go into each room to make sure the patient is breathing.

An interview conducted on 4/8/2020 at 12:35 PM with EI # 1, Director of Nursing, confirmed the facility policy for observation of suicidal patients was not followed.

2. PI # 2 was admitted to the psychiatric MHCU on 2/19/20 with diagnoses including Depressive Disorder and Suicidal Ideation.

Review of the MR revealed PI # 2 presented to the ED on 2/19/20 at 12:55 PM with depression and stated "I have nothing to live for anymore. I am alone all the time. I think about leaving this world all the time...always thinking of a way but never wants to act on them".

Review of the C-SSRS dated 2/19/20 at 1:10 PM in the ED revealed: "thoughts of hanging in the past month, suicide by cop and jumping on a knife, daily."

Suicide Risk Score: High Suicide Risk

Review of the MR order summary revealed a medical order dated 2/19/20 at 5:46 PM for continuous visual observation.

Review of the hand written verbal admission orders dated 2/19/20 at 9:30 PM revealed "Routine Standing Orders" and "CIWA (Clinical Institute Withdrawal Assessment) protocol." There were no orders for the observation level and frequency nor for safety precautions.

Further review of the MR order summary revealed nursing orders dated 2/19/20 at 9:36 PM for suicide precautions, and routine observation every 15 minutes.

There was no documentation the psychiatrist was notified of the patient's High Suicide Risk score which indicated the need for 1:1 observation. Further, there was no documentation in the MR of the rationale, as directed in policy, for decreasing the observation level from CVO to routine every 15 minute observation.

Review of the RN admission assessment dated 2/20/20 at 12:54 AM revealed PI # 2 had a history of depression, anxiety, substance withdrawal, and past psychiatric treatment in the MHCU.

Further review of the RN admission assessment dated 2/20/20 revealed PI # 2 rated his/her depression as 10 and answered "yes" to the following C-SSRS Safe-T assessment questions:
Past month, wished to be dead or go to sleep & not wake up;
Past month, actually had thoughts of killing yourself;
Past month, have been thinking of how you might do this;
Past month, had thoughts with some intention to act;
Lifetime, have you started / prepared to end life;
Was it within the past 3 months?

Suicide Risk Level: High Suicide Risk.

Review of the Treatment Plan dated 2/19/20 at 9:45 PM revealed Problem Number 1 was Suicide Ideation/Plan/Attempt as evidenced by isolative, hopelessness and helplessness.
Nursing Intervention: Assess patient through 1:1 contact for suicidal ideation and ask direct questions related to suicidal thoughts or mood. Encourage patient to contract for safety every shift. Perform environmental rounds/safety checks per precaution level every 15 minutes. Nursing will complete a Suicide Risk Assessment every shift and report to Psychiatrist scores of greater than 16.

There was no documentation of the patient's Suicide Risk Score or ordered observation level on the treatment plan.

Review of the MR revealed the next suicide assessment was completed on 2/21/20 at 7:30 PM, which was 43 hours and 42 minutes later, and not every shift as documented on PI # 2's treatment plan.

Review of the Q 15 minute observation sheets dated 2/19/20 to 2/25/20 revealed the area at the top of each form which indicated the Level of Observation, Frequency of Observation, and Type of Precautions in Place, were left blank. The RN failed to monitor the 15 minute observations by the PCA and ensure documentation on the form was complete and accurate.

Review of the physician assessment/plan dated 2/20/20 and dictated at 10:01 AM revealed PI # 2 had 3 prior psychiatric hospitalizations and no suicide attempts, initially presented to the ED intoxicated...verbalizing suicidal ideations...after..sober up...continued to verbalize suicidal ideations with a plan to stab himself to the heart...reports feelings of hopelessness...feels like he/she is a burden and is tired of his/her life...on exam (examination)...continues to report suicidal ideations as well as depressed mood and neurovegatative symptoms of depression.

Review of the nurses note dated 2/21/20 at 8:30 AM revealed "pt (patient) isolated to room...anxiety rated at 7 and depression 9/10 ( 9 out of 10)...when asked about SI (suicidal ideations)..states "not today" then stated "not yet today"...

There was no documentation a suicide risk assessment or screening was performed.

Review of the physician's progress note dated 2/21/20 and dictated at 1:09 PM revealed PI # 2 "continues to report passive suicidal ideations."

Review of the Frequent Screener documentation in the MR revealed the following questions:
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts w/some (with some) intention to act on them?
Have you started to work out / worked out a plan?
Have you ever done / started / prepared to end your life?

The above questions were answered "no" with Suicide Risk Level as "No Risk" at the following times:
2/21/20 at 1930 (7:30 PM)
2/22/20 at 1925 (7:25 PM)
2/23/20 at 1955 (7:55 PM)
2/24/20 at 1201 (12:01 PM)
2/25/20 at 1030 (10:30 AM)

There was no documentation the staff completed a Suicide Risk Assessment every shift according to PI # 2's treatment plan and there was no documentation the patient was placed on 1:1 nor continuous visual observation as directed per the facility policy for suicidal patients.

A phone interview conducted on 4/8/2020 at 12:45 PM with EI # 1, Director of Nursing, confirmed the suicide assessment was not completed, the observation sheets failed to be completed with the observation level and safety precautions, and the policy for suicidal patients observation level was not followed.

3. PI # 3 was admitted to the facility on 2/25/2020 with a diagnosis of Unspecified Depressive Disorder.

PI # 3 arrived to the MHCO on 2/25/2020 at 9:00 PM.

Review of the Observation Form dated 2/25/2020 revealed the Observation/Frequency was LOS (line of sight) and no documentation of the Type of Precautions.

Further review of the Observation Form dated 2/25/2020 revealed no documentation of every 15 minute observations between 9:15 PM to 11:45 PM.

Review of the Observation Forms dated 2/26/2020, 2/27/2020, 2/28/2020, 3/2/2020 and 3/3/2020 revealed no documentation of Observation/Frequency or Type of Precautions.

The RN failed to monitor the 15 minute observations by the PCA and ensure observations were completed and documentation on the form was complete and accurate.

A written question was submitted to EI # 1 on 4/2/2020 asking if there was documentation of every 15 minute observation on 2/25/2020 between 9:15 PM to 11:45 PM. A written response was received from EI # 1 on 4/2/2020 at 4:49 PM stating, "I have reviewed the chart and there is not an observation form for those dates".