HospitalInspections.org

Based on review of quotes for psychiatric unit renovations, healthcare authority meeting minutes, Governing Body meeting minutes, observations, hospital policies, medical record reviews, and interviews the hospital failed to:

1. Assure a safe environment was provided to Patient Identifier (PI) # 1 and PI # 2. As a result of this failure PI # 1 was able to hang himself with the hem of a patient gown that was secured around a bathroom door knob that resulted in PI # 1's death. PI # 2 was able to elope from the hospital psychiatric unit and was later apprehended by police in another state. Refer to A-115

2. Assure that suicide risk assessments levels were properly assigned to patients with a past medical history of suicide attempts. Refer to A - 395

3. Assure the plan of care was followed for group therapy, individual therapy and activities. Refer to A - 396

4. Assure the staff followed the Alternating Rounding process per policy. Refer to A - 398

This had the potential to affect all patients served in the psychiatric unit.

Findings include:

Refer to A-57, A-115, A-385 A-449 and A-700 for findings.

Based on review of quotes for psychiatric unit renovations, healthcare authority meeting minutes, governing body meeting minutes, observations, hospital policies and interviews the hospital failed to assure a safe environment was provided to Patient Identifier (PI) # 1 and PI # 2. As a result of this failure PI # 1 was able to hang himself with the hem of a patient gown that was secured around a bathroom door knob that resulted in PI # 1's death. PI # 2 was able to elope from the hospital psychiatric unit and was later apprehended by police in another state. The governing body failed to complete psychiatric unit renovations timely to assure the physical environment was safe for all psychiatric unit patients.

This had the potential to affect all patients served.

Findings include:

Refer to A-144, A-385, A-449 and A-724 for additional findings.

A review of the Crenshaw County Health Care Authority meeting minutes was completed. The following information related to the psychiatric unit was discussed on the following dates:

October 2016

The Board discussed adding additional beds to the existing psychiatric unit by purchasing additional beds from another hospital. There was no other documentation of a report for the psychiatric unit.

December 2016

The Board reviewed handouts related to renovations to the psychiatric unit and the possibility of adding new psychiatric beds. There was no other documentation of a report for the psychiatric unit.

January 2017

The Board was presented with an update on the psychiatric unit and changes that were made. There was no other documentation of a report for the psychiatric unit.

March 2017

The Board was presented with all of the costs and options for renovations. The Board was informed the numbers were placed in sections because the renovation needed to begin and not wait until the bed increase issue could be worked out. There was no other documentation of a report for the psychiatric unit.

April 2017

The Board was presented with the expansion and renovation price quotes for the psychiatric unit. The meeting minutes documented the Board felt the top priority was getting the psychiatric unit up to code. There was no other documentation of a report for the psychiatric unit.

June 2017

The Board was informed what the cost would be to purchase 4 additional (Certificate of Need) psychiatric beds and that there was "...some issues..." in the psychiatric unit.

In the topic section titled Administrators Report the following was documented:

Employee Identifier (EI) # 1, Chief Executive Office (CEO), gave the Board packets for repairs that was needed for the hospital. The first item was for a laryngoscope, the Board approved purchasing a new scope. The last item on the list was new countertops for the bathroom. The Board approved the purchase of new bathroom countertops.

There was no other documentation related to the psychiatric unit.

A review of the Governing Body Minutes was completed. The following information related to the psychiatric unit was discussed on the following dates:

October 2016

The hospital was seeking to expand the adult psychiatric unit beds. The Authority Board was waiting until the cost of the beds had been determined before approving an expansion to the renovation project.

November 2016

The hospital continued seeking additional beds to add to the existing psychiatric unit. There was no other discussion on renovations to the psychiatric unit documented.

January 2017

The Board was updated on the status of the additional psychiatric beds. There was no other discussion on the renovations to the psychiatric unit documented.

May 2017

The psychiatric unit renovations "...remains a priority for the Healthcare Authority..." with or without adding new psychiatric beds. There was no other discussion on the renovations to the psychiatric unit documented.

Employee Identifier # 1, Chief Executive Officer (CEO), provided information related to hospital renovations that were discussed related to the psychiatric unit. Two separate quotes were obtained for the work, but none of the purposed renovations had been started for the psychiatric unit at the time of the survey.

Estimate one dated 2/07/17 listed the following items as part of the renovations:

a. plumbing repair/replace
b. heating and air conditioning
c. sprinkler
d. electrical
e. new bathroom
f. new seclusion room
g. new Americans Disability Act (ADA) bathrooms
h. refurbish all patient rooms
i. refurbish corridors

Estimate two dated 4/24/17 listed the following items as part of the renovations:

a. install new floors
b. install new ceiling grid, insulation and tile
c. install new LED lighting fixtures
d. replace most patient doors and hardware
e. replace all bathrooms including tile and plumbing fixtures
f. replace door frames that have rotted out primarily in wet conditions
g. update electrical system
h. upgrade sprinkler system
i. new painting

Interviews

On 8/23/17 at 9:45 AM, an interview was conducted with EI # 2, Certified Registered Nurse Practitioner (CRNP). EI # 2 stated the psychiatric unit was suppose to be updated back in 2012, but nothing has been done yet (no renovation work). EI # 2 stated some rooms do not have adequate lighting and EI # 2 has told staff they would not accept this room for their own mother.

On 8/23/17 at 12:38 PM, EI # 11, Registered Nurse Psychiatric Unit Manager, was interviewed related to the incident with PI # 1. EI # 11 was asked what is done differently now since the incident happened and stated the policy for Mental Health Techs (MHT) rounding was change and now alternate rounding was to be done. The suicide leveling system was changed and is now done daily, which identifies patients at high risk for suicide with a numerical scale. Depending on where the patient scores, determines if the patient's status should change from every 15 minute rounds to a higher 1:1 level of observation. EI # 11 stated there are more patients now on a 1:1 level of observation since the implementation of the suicide leveling system. EI # 11 stated bathroom door knobs were removed and other identified items that might be a potential for harm. EI # 11 stated until the psychiatric unit is remolded the staff try to identify potential problems and that she is trying to increase the staffing on the unit. EI # 11 was asked when the renovations would start in the psychiatric unit and stated around Christmas. EI # 11 confirmed MHTs were to complete the environment rounds and checks and that she would look over them.

On 8/24/17 at 2:40 PM, Employee Identifier (EI) # 23, Chief Executive Officer (CEO), was interviewed. During the interview EI # 23 was asked how long the hospital had been in discussions about renovations to the psychiatric unit and stated about nine months ago was when things got started. EI # 23 was asked if the hospital had a current contract to complete renovations in the psychiatric unit and stated there was a contract with an architect for plans and a bid was received, but the hospital was waiting to see if they could obtain four additional beds to increase the number of psychiatric beds in the unit. EI # 23 was asked what immediate measures was put in place after the incident with PI # 1, who successfully committed suicide while he was a patient on the psychiatric unit. EI # 23 stated a root cause analysis was conducted, bathroom door knobs were removed, a plan was put in place for different rounding (the alternate rounding procedure), clarified definitions for all staff on meaning of 1:1 observations verses within arm's reach, staff education, documentation reviews, video reviews, possible placement of a security guard on the unit, keep closer watch on linen kept in the patient rooms, and changes to the activities program to keep the patients busy and offer patients more options. EI # 23 stated the charge nurse, psychiatric unit manager and Director of Nursing was responsible for assuring these changes were implemented and followed by staff. EI # 23 was asked what immediate measures were put in place after the incident with PI # 2, who successfully eloped from the hospital. EI # 23 stated maintenance came the same night and secured the window PI # 2 eloped from, the roommate in the room with PI # 2 was moved to a new room, staff was placed by the room door and chairs placed in front of the room door to keep other patients from entering the room, and the outside window glass that was broken was replaced. EI # 23 stated in addition, the hospital is looking at using different thermostat covers without a metal frame and that the ceiling was looked at to make sure it was safe. EI # 23 stated the maintenance staff, psychiatric unit nurse manager and staff assigned for completing patient rounds are responsible for assuring these measures are followed. EI # 23 stated the hospital was still completing the root cause analysis at the time of the survey.

On 8/24/17 at 3:20 PM, EI # 11, Registered Nurse Psychiatric Unit Manager, was interviewed a second time. EI # 11 was asked how long the hospital had been discussing renovations to the psychiatric unit. EI # 11 stated since she return to work at the hospital in April 2017 she knew there were discussions, but nothing had been done yet. EI # 11 was asked what the expectation was of staff when completing the rounding tool. EI # 11 stated staff should always complete the tool, leave no blanks, go in the room and lay eyes on the patient. EI # 11 stated the alternate rounding process needed to be ironed out, but the expectation would be the same as for the every 15 minute rounding. If staff get tired or have a lack of focus they should let someone know. EI # 11 confirmed the alternate rounding should be completed at different times than the every 15 minute rounding. EI # 11 was asked about the environment rounds and the follow up that was to be completed for items identified by staff as a concern or potential for harm. EI # 11 stated staff should place a work order, notify the charge nurse on the unit and that she (EI # 11) should follow up to assure the work order was completed. EI # 11 was asked what measures was put in place after the incident with PI # 2, the patient that successfully eloped. EI # 11 stated the glass in the room was fixed, additional screws was placed in the window that was removed, and the roommate was moved to a different room.

On 8/24/17 at 4:15 PM, EI # 21, Director of Nursing (DON) was interviewed. EI # 21 was asked how long the hospital had been discussing renovations to the psychiatric unit. EI # 21 stated for at least one and one half years. EI # 21 stated discussions started when issues were found, then put on hold until a decision could be made about adding beds to the psychiatric unit. EI # 21 stated she knew a contract with an architect had been made, but no work had been started on the renovations. EI # 21 was asked about environmental rounds and the follow up that was to be completed for items that were identified by staff as a concern or potential for harm. EI # 21 stated staff should report issues to the charge nurse and the charge nurse would make a decision if immediate actions were needed by maintenance. EI # 21 stated EI # 11 and EI # 22, Facility Manager, would be responsible for following up to be sure work orders were completed. EI # 21 was asked what the expectation of staff was when completing the round tool. EI # 21 stated staff was to monitor patients closely, chart appropriately and put their eyes on the patients. Staff were to go in the room and check the patient to make sure the patient was actually there and alive. EI # 21 was asked what is different now since the incident with PI # 1. EI # 21 stated bathroom door knobs were removed from all bathroom doors, extra staff were placed on the unit the day of the incident, the suicide leveling process was re-done, alternate rounding was put in place and environmental roundings were to be done each day. EI # 21 was asked who is responsible for assuring staff are following the new procedures and she (EI # 21) stated EI # 11 and then herself.

On 9/01/17 at 11:02 AM, EI # 1, Psychiatrist, was interviewed. During the interview EI # 1 was asked if he felt the hospital environment was safe to treat patients with serious mental illnesses. EI # 1 stated yes, the staff had learned from past experience, were putting patients on 1:1 observation and the observations were more "intense." EI # 1 also stated the building issues needed to be addressed for the long term needs of the psychiatric unit. EI # 1 stated the renovations to the psychiatric unit had been discussed for at least 6 months, the hospital was waiting for extra beds to be approved before moving forward. EI # 1 stated there was no specific date for when the renovations would begin for the psychiatric unit.

The governing body failed to provide a safe environment for PI # 1 and PI # 2 that resulted in PI # 1's death and PI # 2's elopement. The renovation project for the psychiatric unit had been discussed, quotes obtained, but no work had started.

Based on review of video footage from the psychiatric unit, observations, medical record review, police report and interviews, the hospital failed to provide a safe environment for Patient Identifier # 1 and Patient Identifier (PI) # 2. Prior to admission to the psychiatric unit at Crenshaw Community Hospital, PI # 1 was admitted to a separate hospital (Hospital # 1) on 6/08/17 after attempting suicide by hanging himself in a tree. While a patient at Hospital # 1, PI # 1 attempted to hang himself with a piece of his hospital gown. After admission to Crenshaw Community Hospital PI # 1 was found on 6/21/17 in the bathroom with a piece of his hospital gown tied around a bathroom door knob and his neck, which resulted in PI # 1's death. PI # 2 was admitted to Crenshaw Community Hospital on 8/04/17. Prior to PI # 2's admission to Crenshaw Community Hospital PI # 2 had been in jail where he attempted to commit suicide on two separate occasions. On the night of 8/21/17 PI # 2 eloped from the psychiatric unit at Crenshaw Community Hospital and was later apprehended by police in another state. In addition, hospital staff failed to assign the correct suicide leveling to patients, assure staff completed alternating rounding per policy, maintain the physical environment free of potential ligature risk and assure the environment was clean and in good repair.

This had the potential to affect all patients placed in the psychiatric unit.

Findings include:

Refer to A-144, A-398, A-449 and A - 724 for findings.

Based on review of video footage from the psychiatric unit, observations, medical record review, police report and interviews, and hospital policy, the hospital failed to provide a safe environment for Patient Identifier # 1 and Patient Identifier (PI) # 2. Prior to admission to the psychiatric unit at Crenshaw Community Hospital, PI # 1 was admitted to a separate hospital (Hospital # 1) on 6/08/17 after attempting suicide by hanging himself in a tree. While a patient at Hospital # 1, PI # 1 attempted to hang himself with a piece of his hospital gown. After admission to Crenshaw Community Hospital PI # 1 was found on 6/21/17 in the bathroom with a piece of his hospital gown tied around a bathroom door knob and his neck, which resulted in PI # 1's death. PI # 2 was admitted to Crenshaw Community Hospital on 8/04/17. Prior to PI # 2's admission to Crenshaw Community Hospital PI # 2 had been in jail where he attempted to commit suicide on two separate occasions. On the night of 8/21/17 PI # 2 eloped from the psychiatric unit at Crenshaw Community Hospital and was later apprehended by police in another state. In addition, hospital staff failed to assign the correct suicide leveling to patients, assure staff completed alternating rounding per policy, maintain the physical environment free of potential ligature risk and assure the environment was clean and in good repair.

This had the potential to affect all patients placed in the psychiatric unit.

Findings include:

Refer to A-398, A-449 and A - 724 for additional findings.

Medical Record:

Patient Indentifer # 1

Medical Record documentation from Hospital # 1, prior to Patient Identifier (PI) #1's admission to Crenshaw Community Hospital's psychiatric unit.

PI # 1 was admitted to Hospital # 1 on 6/08/17 with the diagnoses of Suicidal Ideations, Paranoid Schizophrenia, Hallucination and Panic Attack.

Review of the Psychosocial Assessment performed at Hospital # 1 on 6/08/17 revealed the patient was found "hanging in a tree and was cut down by the law enforcement and was taken to the hospital." Patient stated "lots of stressors in life that is why he decided to hang self."

The patient was subsequently admitted to Hospital # 1's psychiatric unit.

During the staff's rounds on 6/09/17 at 10:28 PM, the staff who was making rounds checked on the patient who was "staying in the bathroom." The staff found strips of a torn gown made into a noose in the garbage can. PI # 1 stated he was feeling suicidal and hearing voices. The psychiatrist was notified.

At 2:30 AM on 6/10/17, PI # 1 was placed in a cardiac chair (geri-chair) at the nursing station in full view of the staff at all times "related to his suicide attempt."

At 7:26 AM on 6/10/17, the Mental Health Tech (MHT) noted the patient was "covering his head with a blanket" while in the cardiac chair (geri-chair) in full view of the nursing station. The MHT redirected PI # 1 a few times and asked what he was doing. PI # 1 did not respond to the redirection, so the MHT pulled the blanket off and noted the patient was attempting to "chew on the water pitcher cover." The MHT then removed the water pitcher from the patient.

At 9:40 PM on 6/10/17, patient swallowed "markers" while in the dayroom. It was documented that when the staff turned, the patient "snatched marker and swallowed it." Nurse observed the patient "threw up marker." Further documentation stated the patient was unsure on how many markers he swallowed. Psychiatrist was notified and X-rays were taken. Patient was also place on 1:1 precautions in full view of the nursing station.

On 6/11/17 at 1:16 AM Group Note: patient asleep in cardiac chair (geri-chair) at the nursing station with 1:1 sitter in attendance.

Review of Group Note on 6/12/17 at 2:00 PM, staff spoke with patient who was in a cardiac chair (geri-chair) with 1:1 precautions in the hall. Patient stated that he has just had "enough and tried to hang (himself) but the officer cut (him) down." The staff further documented the patient "seems hopeless about (his) future." Patient reports hallucinations. Patient is also homeless.

Review of the Group Note on 6/12/17 at 7:36 PM revealed the patient verbalized being "OK" and denied any current thoughts of suicidal ideations.

Review of the Daily Focus Assessment Report revealed no clear indication when the patient was released from the geri-chair (cardiac chair) to a regular bed with 1:1 precautions until 6/13/17 at 12:37 AM

Medical Record review from Crenshaw Community Hospital for PI # 1

A review of the consultation report from Hospital # 1 documented Patient Identifier (PI) # 1 was taken to a hospital after the police was called reporting PI # 1 was up in a tree. When the police arrived PI # 1 jumped from the tree hanging himself with his toes barely touching the ground. It was documented PI # 1 was initially unconscious and unresponsive, but resumed consciousness about 30 seconds after the police cut the rope. PI # 1 reported to hospital staff he had been drinking and not taking his medication. PI # 1 reported he was hearing voices telling him to hang himself. PI # 1 had a past psychiatric history of schizophrenia with previous attempts to overdose and hang himself. After PI # 1 was admitted to Hospital # 1 he again attempted to hang himself while in Hospital # 1 by using a piece of his hospital gown. PI # 1 was placed on one to one observations at Hospital # 1 due to suicidal ideations. On 6/15/17 PI # 1 was admitted to Crenshaw Community Hospital under a court order.

A review of the death summary from Crenshaw Community Hospital documented PI # 1 was admitted on 6/15/17. Initially PI # 1 was placed on continuous observation along with suicide and homicide precautions. On 6/18/17, PI # 1 was seen by the treatment team and "...did not have active suicidal ideation" and constant observation was discontinued. On 6/19/17, PI # 1 assaulted a male peer on the psychiatric unit and PI # 1 was placed on one to one observation. On 6/20/17, PI # 1 was seen by his treatment team. It was noted PI # 1 continued to have paranoia and hallucinations. On 6/21/17, PI # 1 was seen by Employee Identifier (EI) # 2, Certified Registered Nurse Practitioner (CRNP) and a case manager at 10:30 AM. PI # 1 denied suicidal or homicidal ideations, reported his auditory hallucinations were decreasing and he appeared "...future oriented." On 6/21/17 at 10:50 AM, one to one observation was discontinued and PI # 1 was placed on every 15 minute checks. On 6/21/17 at 2:15 PM, PI # 1 was found in the bathroom of his room deceased from hanging. PI # 1 made a ligature from the hem of his gown which was placed around his neck and the bathroom door knob. The cause of death was suicide by hanging / asphyxiation.

A review of the nursing note for PI # 1 dated 6/21/17 documented the following information:

8:20 AM - Patient alert, oriented to person, place, time; out of room for short periods of time; flat affect; self seclusion behaviors; limited insight. Patient denies suicidal ideations, reports feeling "better" today. Will continue with close observation.

9:20 AM - Patient quite, in room, limited eye contact; continues on close observation.

10:50 AM - Patient saw EI # 2, CRNP, and constant observation was discontinued.

12:20 PM - Patient out of room eating lunch in dayroom.

2:15 PM - "While writer on lunch code blue on south wing called; it was reported patient was found on floor unresponsive by (EI # 4, Mental Heath Tech and EI # 5, Activities Coordinator). Writer assisted staff by getting stretcher on unit, multiple staff members in room with pt (patient)."

2:18 PM - EI # 7, Emergency Room Physician, on floor doing assessment of PI # 1. EI # 7, "...looked up shaking his head; pt was pronounced dead..." at 2:20 PM by EI # 7.

A review of the close observation flowsheet dated 6/21/17 was completed. This tool is used by Mental Health Techs (MHT) to document the every 15 minute checks on the patients that are assigned for the MHT to observe. The flowsheet documentation from 11:00 AM to 1:45 PM was all completed by Employee Identifier (EI) # 10, Mental Health Tech, that was assigned to make observations on PI # 1 on 6/21/17. There was one entry, at 1:45 PM that was completed by EI # 4, MHT. The last entry on the close observation form was documented at 2:00 PM, by EI # 10. The behavior code documented at 2:00 PM, listed PI # 1 was sleeping.

A review of the video camera footage dated 6/21/17 that recorded the room door to PI # 1's room and hallway outside of his room was reviewed by surveyors and hospital staff. The time frame reviewed started at 11:07 AM and ended at 2:28 PM, after PI # 1's death. EI # 10 is seen on the video footage at 11:36 AM to 11:45 AM, but she did not enter PI # 1's room and did not check on PI # 1. From 12:11 PM to 12:20 PM, EI # 10 is seen in the hall at different points in time moving chairs and entering the nourishment room, but not making visible observations of PI # 1. At 12:28 PM, PI # 1 is seen entering his room and he does not leave his room again. EI # 10 documented on the close observation flowsheet that she observed PI # 1 at 12:30 PM, 12:45 PM, 1:00 PM, 1:15 PM, 1:30 PM, and 2:00 PM. However, the video footage reviewed from 12:30 PM until 1:17 PM does not show EI # 10 on camera. EI # 10 is last seen making an observation of PI # 1 at 1:21 PM. At 1:45 PM, EI # 4, MHT, documented on PI #1's flowsheet he was in his room having quite time. However, a review of the video footage does not show EI # 4 checking on PI # 1 at this time. The last video footage of PI # 1 being observed by EI # 10 was at 1:21 PM. No other unit staff observed PI # 1 until 2:16 PM, when EI # 14, Registered Nurse (RN) walked by PI # 1's room and looked in the door without entering the room. At 2:18 PM, EI # 14 and EI # 4, MHT, are observed entering PI # 1's room. At this time multiple staff enter the room. The code team arrives to PI # 1's room at 2:19 PM and PI # 1 is pronounced dead at 2:20 PM by the Emergency Room Physician.

A review of the payroll report, which shows the times EI # 10 clocked in and out on 6/21/17, was reviewed. The report showed EI # 10 clocked out for lunch at 1:59 PM and returned at 2:27 PM.

A review of the police report was completed. The narrative report documented verbal statements were taken from EI # 14, RN, and EI # 4, MHT. Both employees advised they had not seen PI # 1 for "...about 20 minutes or longer." EI # 4 stated she went to PI # 1's room and she did not see him. When EI # 4 opened the bathroom door she found PI # 1 slumped over, back against the bathroom door, with a green string tied around his neck. It was believed PI # 1 tore a strip of material from the hospital gown, placed it around his neck, attached it to the inside door knob of the bathroom resulting in his death.

Hospital staff failed to observe PI # 1 every 15 minutes as determined by his treatment team giving PI # 1 the opportunity to cause harm to himself that resulted in his death. In addition, hospital staff discontinued 1:1 observations of PI # 1 even though PI # 1 had multiple recent attempts to commit suicide prior to his admission at Crenshaw Community Hospital. The physical environment of the psychiatric unit contained door knobs on the bathroom doors that allowed a point of support for the ligature that PI # 1 made out of a hospital gown.

Patient Identifier # 2

Patient Identifier (PI) # 2 was admitted to the hospital on 8/04/17 for depression and suicidal ideation.

A review of the discharge summary for PI # 2 documented he was admitted on transfer from jail following a suicide attempt. PI # 2 had a "...significant suicide risk..." including a brother and father who completed suicide. PI # 2 was identified with poor frustration tolerance and impulsivity. PI # 2 cut himself in jail, sutures were applied and he later ripped those stitches out and started cutting himself again. PI # 2 was under a court order and placed in the psychiatric unit at Crenshaw Community Hospital. On 8/15/17 his treatment team met and he continued to have significant suicide risk. PI # 2 was continued on suicide and homicide precaution. On 8/21/17, PI # 2 eloped from the hospital and local law enforcement was notified.

A review of the history and physical for PI # 2 documented he had a past psychiatric history of bipolar mood disorder.

A review of the physician orders for PI # 2 revealed he was placed on 1:1, line of sight, level of observation on 8/07/17 at 1:00 PM. This level of observation was discontinued on 8/09/17 at 11:05 AM, and PI # 2 was placed on every 15 minute checks. PI # 2 remained on every 15 minute checks until he eloped from the psychiatric unit on 8/21/17 at 9:30 PM.

A review of the video camera footage from 8/21/17 starting at 8:45 PM and ending at 10:20 PM was conducted with surveyors and hospital staff. The video footage showed PI # 2 in the hallway wearing a bright green t-shirt at 8:45 PM. At 8:53 PM, PI # 2 is seen coming out of his room wearing a solid white t-shirt. At 8:54 PM, PI # 2 enters his room and is not seen again on the camera footage. At 9:08 PM, three hospital staff are seen entering PI # 2's room. At 10:14 PM, EI # 22, Facility Manager, is seen entering PI # 2's room and later returns at 10:19 PM with a drill in his hand. The drill was used by EI # 22 to replace screws in the plexiglass that PI # 2 removed when he eloped.

A review of the Mental Health Tech Rounding Log, used by MHT staff assigned to observe patients and document on the patient every 15 minutes was reviewed. On 8/21/17 at 9:00 PM, EI # 24, MHT, documented PI # 2 was in his room quietly resting. The video camera footage at 9:00 PM did not show EI # 24 observe PI # 2 at this time.

After the incident with PI # 1, patient that successfully committed suicide in the psychiatric unit, alternating rounds were implemented by the hospital in an effort to keep patients from learning the routine every 15 minute checks that staff was suppose to complete. The process implemented was for assigned staff to complete the every 15 minute observations on the quarter hour schedule and then an alternate staff person was assigned to complete observations of the patient at times other than the quarter hour observations. A review of the Alternating Nurse / MHT Rounding Log, where staff were to document observations at times other than the quarter hour observations, for PI # 2 was reviewed. The alternating rounding tool documented alternating observations were completed at the same time as the scheduled observations for the following dates and times:

8/05/17: from 9:00 AM to 9:30 AM and 3:00 PM to 7:15 PM and 7:15 AM to 9:00 AM (the next morning)
8/06/17: from 9:00 AM to 1:15 AM (the next morning) and 2:00 AM to 4:30 AM and 5:15 AM to 6:00 AM and 6:15 AM to 7:30 AM.
8/10/17: from 7:00 PM to 6:00 AM (the next morning) and 6:45 AM to 7:15 AM and 7:45 AM to 8:15 AM
8/11/17: from 6:30 PM to 7:00 PM and 7:30 PM to 10:15 PM
8/12/17: from 10:00 AM to 10:30 AM and 8:30 PM to 9:15 PM and 10:00 PM to 6:30 AM (the next morning)
8/13/17: from 10:15 AM to 12:45 PM and 1:00 PM to 2:00 PM and 4:15 PM to 7:15 PM
8/14/17: from 9:00 AM to 9:45 AM and 7:30 PM to 9:00 PM
8/15/17: from 5:00 PM to 7:15 PM and 9:00 PM to 10:00 PM and 2:30 AM to 4:30 AM
8/16/17: from 9:45 AM to 3:00 PM
8/18/17: from 7:15 PM to 11:45 PM
8/19/17: from 2:45 AM to 5:30 AM
8/20/17: from 7:15 PM to 1:00 AM on 8/21/17
8/21/17: from 9:30 AM to 7:00 PM

On 8/24/17, EI # 21, Director of Nursing was given written questions related to the alternate rounding times being documented at the same time as the every 15 minute checks. EI # 21 provided a written response that staff was educated on the new rounding process and the employee involved was hired after the incident with PI # 1 and initial education that was provided to staff.

Staff failed to follow the alternating rounding process on PI # 2 and the hospital failed to assure new staff was educated and following the alternate rounding process. In addition, the physical environment was not kept free of metal items patients could use to remove screws and glass from windows.

Interviews

On 8/23/17 at 8:05 AM, an interview was conducted with Employee Identifier (EI) # 7, Emergency Room Physician. During the interview EI # 7 was asked what he remembered about the incident with PI # 1. EI # 7 stated a code was called and he responded immediately to the psychiatric unit. Upon arrival to PI # 1's room EI # 7 stated the patient (PI # 1) had deep ligature marks around his neck. When examined PI # 1 had a yellowish hue and had been down without oxygen for at least 10 minutes. EI # 7 stated PI # 1 made a make shift rope that he placed around his neck, but had been removed by the time EI # 7 arrived to the patient's room. PI # 1 had an indention to the mid forehead from where he apparently had leaned against a "pole" (handicap grab bar in the bathroom). EI # 7 stated there was nothing that could be done to resuscitate PI # 1. The patient was non-viable and the code was called.

On 8/23/17 at 8:40 AM, an interview was conducted with EI # 14, Registered Nurse (RN). During the interview with EI # 14 he was asked what he remembered about the incident with PI # 1. EI # 14 stated he was the medication nurse on the day of the incident. EI # 14 stated he looked in the patient's room and did not see the patient on the bed. EI # 14 stated he asked EI # 4, Mental Health Tech (MHT) if PI # 1 had been discharged. Both EI # 14 and EI # 4 returned to PI # 1's room. EI # 4 opened the bathroom door and said, "Oh my god he hung himself." EI # 14 stated he called the code blue, gathered gloves and an ambu bag and returned to the room. EI # 14 stated EI # 7 arrived and said not to do any resuscitation measures. EI # 14 stated the local police came and he gave a statement to them. EI # 14 stated PI # 1 appeared to be hopeful when he spoke with him earlier in the day and PI # 1 gave no impression that he (PI # 1) was considering harming himself. EI # 14 was asked what is done differently now since the incident with PI # 1. EI # 14 stated in addition to the regular rounds now alternate rounds are done, the suicide tool scores have been updated to better identify the level of risk and that now staff seem to be more "aware" opening doors to see where everyone is.

On 8/23/17 at 9:25 AM, an interview was conducted with EI # 4, Mental Health Tech. During the interview with EI # 4 she was asked what she remembered about the incident with PI # 1. EI # 4 stated she was in the hallway when EI # 14 asked her if she had seen PI # 1. EI # 4 stated she went in the room, opened the bathroom door and PI # 1 was "slumped over, green part of gown around neck - not attached to door - it must have fell off. Slumped facing the door." EI # 14 called a code blue and everyone came. EI # 4 confirmed the bathroom door knobs at the time were round. EI # 4 stated EI # 11, RN Psychiatric Unit Manager, removed the green part of the gown that was around PI # 1's neck and "...laid him down...could tell he (PI # 1) was dead - Emergency Room doctor (EI # 7) said nothing to do." EI # 4 was asked what is done differently now since the incident with PI # 1. EI # 4 stated all bathroom door knobs were removed, an alternate rounding process was put in place and each MHT had regular rounds to make on specific patients.

On 8/23/17 at 9:45 AM, an interview was conducted with EI # 2, Certified Registered Nurse Practitioner (CRNP). During the interview with EI # 2 she was asked what she remembered about the incident with PI # 1. EI # 2 stated she saw PI # 1 and wrote an order to discontinue the 1:1 level of observation that PI # 1 had been placed on the day before for aggressive behavior toward another patient on the unit. EI # 2 stated she saw PI # 1 in treatment team and he appeared to have "really good day". EI # 2 stated PI # 1 "made peace" with the other patient that PI # 1 was aggressive towards and discharge plans for PI # 1 had been discussed. EI # 2 stated she heard the code blue, but she was with a patient. EI # 2 stated another staff member came to tell her that PI # 1 was dead. EI # 2 stated her general impression of PI # 1 the day of the incident was not indicative of suicide, that PI # 1 seemed to be making progression. EI # 2 stated PI # 1 was a high risk for suicide based on his referral and his previous attempts to commit suicide, but EI # 2 felt his acute suicide risk had gone down. EI # 2 stated looking back PI # 1's getting on his knees in the bathroom to hang himself was serious. EI # 2 was asked what is done differently now since the incident with PI # 1. EI # 2 stated the nursing suicide risk assessment had been updated. EI # 2 stated PI # 1 came up "low risk", but EI # 2 felt with his recent attempts to commit suicide prior to his admission to Crenshaw Community Hospital PI # 1 was not a low risk. EI # 2 stated a lot more 1:1 observation status is being done in the unit now, and all bathroom door knobs were removed. EI # 2 stated the psychiatric unit was suppose to be updated back in 2012, but nothing has been done yet (no renovation work). EI # 2 stated some rooms do not have adequate lighting. EI # 2 stated she did not know if the 15 minute checks versus the 1:1 level of observation was appropriate for PI # 1 and agreed the hospital failed PI # 1.

On 8/23/17 at 12:25 PM, an interview with EI # 10, MHT assigned to observe PI # 1 on 6/21/17 was conducted. EI # 10 was asked what she remembered about the incident with PI # 1. EI # 10 stated she was doing 1:1 level of observation on PI # 1. After PI # 1 saw EI # 2, he, (PI # 1) was taken off of 1:1 observation and placed on every 15 minute checks. EI # 2 stated PI # 1 spent a lot of time sitting on his bed. EI # 2 stated at 2:00 PM she gave her board, with the observation rounding tool for PI # 1, to EI # 18, MHT, while EI # 10 went to lunch. EI # 10 stated when she returned from lunch the incident with PI # 1 had already happened. EI # 10 stated the last time she saw PI # 1 he was standing in the doorway of his room. EI # 10 stated PI # 1 did not seem depressed or suicidal on the day of the incident. EI # 10 was asked what is done differently now since the incident with PI # 1. EI # 10 stated alternate rounds have been put in place, where staff check patients between the every 15 minute checks. EI # 10 stated staff are constantly in and out checking on patients. EI # 10 was asked about the environmental rounds and she stated all staff are involved with that process. They check doors, windows and vents in the room.

On 8/23/17 at 12:38 PM, EI # 11, Registered Nurse Psychiatric Unit Manager, was interviewed related to the incident with PI # 1. EI # 11 was asked what is done differently now since the incident happened and stated the policy for Mental Health Techs (MHT) rounding was change and now alternate rounding was to be done. The suicide leveling system was changed and is now done daily, which identifies patients at high risk for suicide with a numerical scale. Depending on where the patient scores determines if the patient's status should change from every 15 minute rounds to a higher 1:1 level of observation. EI # 11 stated there are more patients now on a 1:1 level of observation since the implementation of the suicide leveling system. EI # 11 stated bathroom door knobs were removed and other identified items that might be a potential for harm. EI # 11 stated until the psychiatric unit is remolded the staff try to identify potential problems and that she is trying to increase the staffing on the unit. EI # 11 was asked when the renovations would start in the psychiatric unit and stated around Christmas. EI # 11 confirmed MHTs were to complete the environment rounds and checks and that she would look over them.

On 8/24/17 at 4:15 PM, EI # 21, Director of Nursing (DON) was interviewed. EI # 21 was asked how long the hospital had been discussing renovations to the psychiatric unit. EI # 21 stated for at least one and one half years. EI # 21 stated discussions started when issues were found, then put on hold until a decision could be made about adding beds to the psychiatric unit. EI # 21 stated she knew a contract with an architect had been made, but no work had been started on the renovations. EI # 21 was asked about environmental rounds and the follow up that was to be completed for items that were identified by staff as a concern or potential for harm. EI # 21 stated staff should report issues to the charge nurse and the charge nurse would make a decision if immediate actions were needed by maintenance. EI # 21 stated EI # 11 and EI # 22, Facility Manager, would be responsible for following up to be sure work orders were completed. EI # 21 was asked what the expectation of staff was when completing the round tool. EI # 21 stated staff was to monitor patients closely, chart appropriately and put their eyes on the patients. Staff were to go in the room and check the patient to make sure the patient was actually there and alive. EI # 21 was asked what is different now since the incident with PI # 1. EI # 21 stated bathroom door knobs were removed from all bathroom doors, extra staff were placed on the unit the day of the incident, the suicide leveling process was re-done, alternate rounding was put in place and environmental roundings were to be done each day. EI # 21 was asked who is responsible for assuring staff are following the new procedures and she (EI # 21) stated EI # 11 and then herself.

On 9/01/17 at 11:02 AM, EI # 1, Psychiatrist, was interviewed. EI # 1 was asked about the incident with PI # 1. EI # 1 stated he was informed by EI # 2 of PI # 1's death. EI # 1 was asked what is done differently since the incident with PI # 1 and stated the MHTs are more vigilant, going into the patient's room to talk with the patient and observe the environment to remove items patients could use to hurt themselves with. Door knobs were removed from the bathroom doors in the patient rooms. EI # 1 stated replacement door knobs were needed to be more safe and the renovations needed to be made. EI # 1 stated if the patient does not attend therapy staff should find out why the patient is not attending. EI # 1 stated, "We do not want clients (psychiatric patients) by self sitting" in the room unless they are on 1:1 observation. EI # 1 was asked if he thought it was appropriate to change PI # 1's observation status from 1:1 to every 15 minutes and stated PI # 1 was moving towards progress and the treatment team had discussed discharge plans. EI # 1 stated if the environment had been different and staff were vigilant about the every 15 minute checks he thought the outcome for PI # 1 would have been different. EI # 1 was asked about PI # 2, the patient that eloped from the secured psychiatric unit. EI # 1 stated he was called by a staff RN the night PI # 2 eloped and staff informed him the patient took the window glass out piece by piece and that was how PI # 2 eloped. EI # 1 stated he did not know how PI # 2 was able to remove the glass, but felt PI # 2 coordinated with someone, not sure who, to get out. EI # 1 stated he has visited other psychiatric hospitals and their windows are designed in such a way to prevent patients from being able to elope.

On 9/06/17 at 7:15 AM, EI # 28, Mental Health Tech (MHT), was interviewed. During the interview EI # 28 stated PI # 2 was quiet type, "...always looked like he was up to something." EI # 28 was asked how PI # 2 was able to get out of the unit and stated, "The way I saw it all day long he had to be taking the window loose. From 7:00 PM until 9:00 PM or so he (PI # 2) was in our sight so had to do it on dayshift. Think he used air conditioning cover to pry plastic away from window."

On 9/06/17 at 7:49 AM, EI # 24, MHT, was interviewed. During the interview EI # 24 stated EI # 28, MHT, heard a "pop" sound and a beige piece of metal was found, "...like an old piece of hospital bed. Couldn't find anything on the unit that looked like that." EI # 24 stated two pieces of metal were found, one piece behind PI # 2's head of bed and one in the ceiling covered by a ceiling tile. EI # 24 was asked if she thought hospital staff observed PI # 2 appropriately and she stated, yes. EI # 24 state, "Only thing better (we could do) would be the environmental rounds we do. I think if we would have done the round earlier we would've seen maybe the window."

On 9/06/17 at 8:12 AM, EI # 26, Registered Nurse (RN), was interviewed. During the interview EI # 26 was asked how PI # 2 was able to elope from the psychiatric unit. EI # 26 stated a staff person heard a "pop" sound just before PI # 2 eloped. EI # 26 stated the pop sound was like hearing screws loose being pulled back. EI # 26 stated staff found pieces of glass in PI # 2's room at the head of his bed and a cubbie hole. EI # 26 felt PI # 2 had prior opportunities to remove glass from the window which allowed PI # 2 to elope so quickly from the unit. EI # 26 stated the cover was off the heating control. The heating control is supposed to be locked, but it was not "fool proof." EI # 26 stated the heating control was made of heavy metal and could have been used by PI # 2 to lift the plexiglass. EI # 26 also stated the psychiatric unit has drop ceilings with tiles that can be lifted and where patients can "hide things." After PI # 2 eloped, EI # 26 stated she had a MHT lift the tiles and staff found a piece of metal in the ceiling. EI # 26 stated that is the the type of stuff that has to be worked on and rectified. EI # 26 was asked what is done differently since the incident with PI # 2 and stated the environmental rounds have been "beefed up" and now staff look past the plexiglass and staff now conduct alternate rounding. EI # 26 stated MHT were assigned to make the environmental rounds on the unit.

Policy title: Patient Rounds

Revised: 7/05/17

It is the policy of the Special Services Unit (psychiatric unit) to provide a safe environment for the patients by conducting patient rounds.

Purpose: To ensure consistent and continuous surveillance of patients and the physical building and to assess the safety of each patient and the physical unit routinely.

Procedure: Patient rounds may be done by unit personnel to include visualization of each patient. Rounds shall be made at least every 15 minutes per 24 hour day. Alternating rounds will be done on each patient between the 15 minute rounding times, but not on the fifteen minute time frame. Example: Normal 15 minute rounds are done 0800 and 0815 the alternating rounds will be done at no specific times. For example, close observation rounds are made on every 15 minute increment. The alternating rounds are to be performed by an assigned Nurse / Mental Health Tech every shift that will do a non-scheduled round between every 15 minute close observation round. Environmental safety rounds on all rooms and unit will be done on each shift.

Policy title: Close Observation/ 1:1 Observation of Patients

Patients admitted to the psychiatric unit are placed on suicidal/homicidal precautions and will be monitored under close observation. Patients who are actively suicidal or homicidal and score a level 1 / imminent risk on the suicide assessment will be placed on 1:1 line of sight (LOS) or 1:1 within arm's reach (WAL) according to the physician's order. Patients that score a Level 2 / moderate risk may be upgraded and placed on 1:1 LOS or 1:1 WAL according to physician's order.

Procedure:

Close Observation
A. All patients shall be placed on Close Observation for the duration of the hospitalization.
1. Close observation require that staff monitor the patient by direct visual contact every fifteen minutes which will be documented on an Observation Log sheet.

1:1 Line of Sight (LOS)
A. 1:1 Line of Sight requires that staff constantly monitor the patient with the line of sight observation and document this observation every 15 minutes on the Observation Log sheet.

1:1 Within Arm's Reach (WAL)
A. 1:1 Within arm's reach requires that staff remain within arm's length of the patient at all times and document this observation every 15 minutes on the Observation Log sheet.

Environmental observations:

During a tour of the hospital on 8/22/17 at 8:50 AM, with Employee Identifier (EI) # 23, Chief Executive Office (CEO), the surveyors observed the following environmental hazards:

Shower room on unit: only contained one dimly lit light that had a crack

Based on hospital policy, record review and interview the hospital failed to:

1. Assure that suicide risk assessments levels were properly assigned to patients with a past medical history of suicide attempts.

2. Assure the plan of care was followed for group therapy, individual therapy and activities.

3. Assure the staff followed the Alternating Rounding process per policy.

This had the potential to affect all patients served.

Findings include:

Refer to A-395, A-396 and A-398 for findings.

Based on medical record review, interviews and policy, the hospital failed to assure that suicide risk assessments levels were properly assigned to patients. Patient Identifier (PI) # 1 had multiple previous attempts to commit suicide, but his admission suicide leveling score was documented at a level 3, low to no risk. On 6/21/17 PI # 1 used the hem from his gown to create a ligature and hang himself in his patient room bathroom resulting in PI # 1's death.

This affected PI # 1, PI # 13 and PI # 3, three of fifteen records reviewed and had the potential to affect all patients served.

Findings include:

Policy:

Facility Special Services Education and Staff Meeting
Effective Date: June 6 - June 7, 2017

"Suicide Education:

...5. Documentation

a. Suicide leveling Assessment Tool: This tool has been created to ask specific questions related to suicide or self-harm using a point system to determine the level of risk per patient. This assessment must be performed on admission and at a minimum of every 24 hours a day to reassess. However, if at any time the Nurse and/or MHT (Mental Health Technician) determine that the patient has had changes then the Suicide Leveling System should be done to assess for the need to increase the patient's level or need for 1 to 1 observation ...

Suicide Leveling System Assessment (New) and Documentation Process

1. New Process:

a. All patients will be assessed for suicidal ideations and precautionary measures by using the Suicide Leveling System Assessment Tool on admission and at a minimum of every 24 hours. This does not limit the need to reassess the patient more during your shift or as the patient's need changes throughout his/her stay.

b. Once the nurse finishes assessing the patient's suicide risk and completing the Suicide Leveling System Tool the nurse then assigns a level and informs the Physician (MD) or LIP (Licensed Independent Practitioner) of the need to increase the patient's observation status. After notification of the MD and/or LIP the nurse will inform the assigned MHT of the patient's observation status and of any increased observation (i.e. [example] One-on-One).

c. There are 3 different observation categories: 15 Minute Checks (Routine checks), 1:1 LOS (one-to-one in line of sight) and 1:1 WAL (one-to-one within arm's length).

Medical Record:

1. Patient Identifier (PI) # 1's past medical history included an admission at Crenshaw Community Hospital on 1/31/17 with a chief complaint of suicidal ideation, auditory and visual hallucinations. Documented in the history and physical from the 1/31/17 hospital admission it listed PI # 1, "Hears voices with commands for suicide and homicide, he has been thinking about hanging himself, spirits and dead people up here as visual hallucination. Reports that two weeks prior to admission, he took a bunch of Suboxone and almost died, did not receive treatment. He has been thinking about suicide since." Under the family history section of this history and physical it was documented, "He (PI # 1) reports there is a paternal history of serious mental illness, that paternal grandfather and a paternal uncle suffer serious mental illness and there have been a couple of suicides."

The history and physical for the 6/15/17 hospital admission documented PI # 1's history of present illness as follows, "The patient attempted suicide by hanging, has been feeling homicidal. He has been hallucinating, paranoid, delusional. He tried to hang himself jumped from the tree and hanged. Police had to cut him down. He lost his consciousness." Under the family history section of this history and physical it was documented, "Paternal grandfather and paternal uncle suffer serious mental illness. There had been a couple of suicides."

A review of the Crenshaw Community Hospital Pre-Screen evaluation form dated 6/14/17 was completed. The section of the form titled synopsis of recent medical history documented PI # 1 was admitted to Hospital # 1 on 6/08/17 after a suicide attempt by hanging and police had to cut PI # 1 down from the tree. PI # 1 attempted to hang himself and swallowed three markers while a patient at Hospital # 1.

A review of the Crenshaw Community Hospital interdisciplinary care plan dated 6/15/17 documented PI # 1's circumstances of admission were suicide attempt, tried to hang self in the woods and PI # 1 attempted to hang self while a patient at Hospital # 1.

A review of the Crenshaw Community Hospital psychosocial history and evaluation tool dated 6/16/17 was completed. The section of the form titled presenting complaint documented PI # 1 had "auditory and visual hallucinations tired to hang himself in the woods, the police cut him down - he lost consciousness." PI # 1 swallowed three markers and attempted to hang himself while a patient at Hospital # 1. The section of the form titled thought content documented PI # 1 "hears voices - hurt himself - hurt others."

The suicide leveling system form dated 6/15/17 was reviewed. PI # 1's suicide precaution level was documented at a level 3, low to no risk. The level 3 target symptoms listed the following:

1. The patient with vague/fleeting thoughts of suicide but without a plan.
2. The patient who is willing to make a no suicide contract.
3. The patient with insight into existing problems.
4. The patient judged low on the suicide lethality scale.

Nursing interventions for a level 3 listed the following:

1. All staff check patient's whereabouts every 15 minutes.
2. Frequent verbal contact while awake.
3. Place patient in a room close to the nursing station.
4. Place patient on Close Observation.

On 8/23/17 at 9:45 AM, an interview was conducted with EI # 2, Certified Registered Nurse Practitioner (CRNP). EI # 2 stated PI # 1 was a high risk for suicide based on his referral and his previous attempts to commit suicide, but EI # 2 felt his acute suicide risk had gone down. EI # 2 stated looking back PI # 1's act on his knees to harm himself was serious. EI # 2 was asked what is done differently now since the incident with PI # 1. EI # 2 stated the nursing suicide risk assessment had been updated. EI # 2 stated PI # 1 came up "low risk", but EI # 2 felt with is recent attempts to commit suicide prior to his admission to Crenshaw Community Hospital PI # 1 was not a low risk. EI # 2 stated she did not know if the 15 minute checks verses the 1:1 level of observation was appropriate for PI # 1 and agreed the hospital failed PI # 1.

On 8/23/17 medical record questions were presented to Employee Identifier (EI) # 21, Director of Nursing. The surveyor asked how staff determined a level 3 for PI # 1 with his recent attempt to hang himself. EI # 21 provided a written response back to the questions on 8/24/17 stating the Registered Nurse (RN) assessed the patient on admission and completed his suicide leveling form based on the RN's assessment performed 6/15/17 and did not complete the form by PI # 1's pervious history. The admission RN told EI # 21 the patient said he had no plan and did not want to hurt himself but he had previously attempted suicide. The admission RN acknowledged that the suicide level should have been made a level 1 due to PI # 1's recent history and that PI # 1 was placed on one to one observation on admission. EI # 21's written response also included after PI # 1 committed suicide while a patient on the psychiatric unit the hospital determined a more individualized questionnaire that had a scoring system for each question should be used and was developed. Each question on the suicide leveling scoring system is related to the patient's current assessment and the patient's history to determine the need for closer monitoring.

On 6/21/17 PI # 1 used a hem of a patient gown to make a ligature, tied the ligature around his bathroom door knob and hung himself resulting in his death. Hospital staff failed to assign the appropriate suicide level to PI # 1 on admission.



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2. PI # 13 was admitted to the facility 8/22/17 with diagnoses including Bipolar Disorder and Suicidal Ideation (SI).

Review of the Initial Nursing Assessment dated 8/22/17 at 8:05 PM revealed documentation as follows:

a) Precipitating Events (Past 24-72 Hours): Depressed, hallucinations, paranoid ideation, SI - plans to take pills or use gun if in possession, voices telling (him/her) to hurt self, seeing shadows, feels worthless.

b) Psychiatric Complaints and Stressors: Agitation, Excessive guilt, Mood swings, Anxiety, Excessive worry, Panic attacks, Delusions, Feelings of worthlessness and Hallucinations.

c) Special Precautions Recommendations: Suicidal - Yes, Homicidal - Yes.

Review of the Suicide Leveling System Assessment dated 8/22/17 at 8:05 PM reveled the following documentation:

a) Suicidal Thoughts: None Present
b) Suicidal Plan: None Present
c) Suicidal Intent: None Present

Patient Score and Risk: 10 Low Risk/Level 3

In an interview conducted 8/24/17 at 3:20 PM with EI # 11, Registered Nurse Psychiatric Unit Manager, EI # 11 was asked to explain how the staff assessed each patient's risk using the new Suicide Leveling System Assessment tool. EI # 11 stated each question was asked/answered based on the patient's status at that time not on past history.

In an interview conducted 8/24/17 at 4:15 PM with EI # 21, Director of Nursing, EI # 21 was asked to explain how the staff assessed each patient's risk using the new Suicide Leveling System Assessment tool. EI # 21 stated each question was asked/answered based on the patient's history and current status.

2. PI # 3 was admitted to the facility 6/6/17 with diagnoses including Bipolar Mood Disorder and Suicidal Ideations. PI # 3 was an involuntary transfer from another facility.

Review of the medical record (MR) revealed PI # 3 had tied a sheet around his/her neck and attached it to the television stand while at the transferring facility. Review of medical and psychosocial history revealed PI # 3 shot himself in the chest 6-7 years prior and had a history of two more attempts by cutting wrists and hanging.

Review of the Suicide Leveling System tool dated 6/6/17 revealed PI # 3 was placed on Level 2 Suicide Precautions Moderate Risk.

Further review of the Suicide Leveling tool revealed patients who have attempted suicide in the recent past by a particularly lethal method, i.e., hanging, guns, or carbon monoxide would be Level 1 Suicide Precaution Imminent Risk.

Review of the 7 AM - 7 PM nursing documentation dated 6/7/17 revealed at 3:05 PM PI # 3 was "up at desk c/o (complaining of) feeling agitated, anxious. Med nurse notified to give patient a Vistaril. Will continue with close observation." At 4:05 PM "patient was found in room with gown wrapped tightly around neck standing on garbage can up against bathroom door attached attempting to hang self. Patient had to be assisted to floor with several staff and gown cut from patient's neck...patient placed on 1:1 (one to one) observation."

Review of the Close Observation Flowsheet dated 6/7/17 revealed at 3:15 PM the patient was located in PR (patient room) and Behavior/Activity was QI (quiet time). At 3:30 PM, 3:45 PM, 4:00 PM the flowsheet dated 6/7/17 documented 1:1.

Review of the One to One Flowsheet dated 6/7/17 revealed 1:1 began at 4:15 PM.

When questioned regarding the Close Observation Flowsheet dated 6/7/17 with 1:1 documented at 3:30 PM, 3:45 PM and 4:00 PM EI # 21 responded the MHT documented inappropriate time for start of 1:1.

There was no documentation of the patient's location and behavior/activity from 3:15 PM to 4:05 PM when he/she was found with the gown wrapped around his/her neck.

Written questions were submitted 8/23/17 to EI # 21 regarding the Suicide Leveling System assessment of PI # 3. Written responses were received 8/24/17 from EI # 21 which stated that PI # 3 should have been placed as a Level 1 Suicide Precaution based on number 5 (recent attempt) on the Suicide Leveling form.

Based on hospital policy, record review and interview the hospital failed to assure the plan of care for Patient Identifiers (PI) # 1, PI # 2, PI # 3 and PI # 4 was followed for group therapy, individual therapy and activities. This affected 4 of 4 records reviewed for care plans and had the potential to affect all patients served.

Findings include:

Facility Policy/Procedure for Special Services: Multidisciplinary Treatment Plans

Policy:

It is the policy of the Special Services Unit that each voluntary or involuntary patient who is on the unit for more than 72 hours will have an individualized treatment plan, which is based upon the assessments of the patient's fundamental needs.

Purpose:

The purpose of the individualized treatment plan is to collate all known pertinent data systematically to reflect the patient's condition based upon multidisciplinary assessments, to delineate intervention and modalities, expectations for treatment goals, and to identify individual service providers...

Procedure:

1. Each treatment plan shall be developed and implemented under the direction of an attending Psychiatrist.

2. All disciplines represented on the treatment team shall have input into the development of the treatment plan as determined by the patients need and this input shall be documented. Problems and needs as determined through assessments made by the clinical professional staff shall be noted and addressed by source.

4. The treatment plan shall include the desired goals and objectives expected from treatment. These goals and objectives shall be expressed in measurable, behavioral criteria stating the time within which the change is expected, the intervention/action required, the clinician responsible for providing specific services and the date the specific goal is reached or discontinued. Goals my be those identified by the patient, staff or other person involved in treatment planning.

5. As changes in the patient's condition are noted, interventions shall be modified to reflect these changes and the goal sheet shall be appropriately updated...

6. Treatment assessment and discharge planning reflects an ongoing, interrelated process that shall be started immediately upon admission and continued through the patients discharge from the unit.

Treatment planning activities will include the following:...

2. Treatment Plan:

The treatment plan is an individualized evolving documentation of patient care. It reflects the multidisciplinary assessments, test, procedures, treatments, and therapy. The plan builds upon the problem list and is to be initiated within 72 hours of hospitalization...

3. Treatment Plan Review:

Treatment plan review meetings will occur weekly through hospitalization. All staff who are responsible for implementing the multidisciplinary treatment plan will participate in the review process. The treatment plan review form will reflect the resolution or revision of problems from the problem list and treatment plan along with progress assessments. Objectives will be behaviorally measurable...The attending physician or the Clinical Director will sign each review as the head of the treatment team.

Medical Record:

1. Patient Identifier (PI) # 1 was admitted to the hospital on 6/15/17 with diagnosis of schizophrenia and a recent history of suicide attempts.

A review of the interdisciplinary care plan dated 6/16/17 was completed. The care plan listed PI # 1's limitations as homeless, lack of insight into illness, non-compliant with treatment and little social support. The care plan included PI # 1 was to attend group and individual therapy.

A review of the group counseling note dated 6/16/17 documented PI # 1 did not attend. The next group provided was on 6/19/17. There was no documentation PI # 1 was encouraged by hospital staff to attend group and there was no documentation PI # 1 was provided individual therapy during his hospital stay per the care plan.

A review of the activities group notes dated 6/16/17, 6/19/17, 6/20/17 and 6/21/17 documented PI # 1 refused to participate in activities. There was no documentation PI # 1 was encouraged by hospital staff to attend group and there was no documentation PI # 1 was provided an alternate activity.

Written questions was submitted to Employee Identifier (EI) # 21, Director of Nursing, on 8/23/17. On 8/24/17 EI # 21 provided written response back related to why PI # 1 did not attend group or activities and if individual group or activities were provided to PI # 1. EI # 21's response was PI # 1 refused to attend groups each time and that a counselor provided individual counseling on 6/16/17 during the psychosocial evaluation. In response to questions on activity groups not being attended by PI # 1, EI # 21's response was EI # 5, Activities Coordinator, stated he requested PI # 1 to attend, but PI # 1 felt anxious in a group setting.

There was no documentation on the 6/16/17 psychosocial evaluation of where individual counseling was provided to PI # 1. The hospital staff failed to provide PI # 1 with group counseling, individual therapy and activities per the established care plan.

2. PI # 2 was admitted to the hospital on 8/04/17 with diagnosis to include depression, suicidal.

A review of the interdisciplinary care plan dated 8/07/17 was completed. PI # 2's limitations listed as lack on insight into illness, non-compliant with treatment and no health insurance. The care plan included PI # 2 was to be provided group therapy, individual therapy and activities.

A review of the group counseling notes was completed with the following documentation noted:

8/07/17 - PI # 2 did not attend. There was no documentation why PI # 2 did not attend group, was encouraged to attend group or that an individual group was offered.

8/08/17 - "There was no 11:00 AM group this morning as TX (Treatment) team started late and continued until after 11:00 AM." There was no documentation the patients were offered a make up group.

8/11/17 - PI # 2 did not attend group. "He was at court." There was no documentation a make up group or individual group was offered to PI # 2.

8/15/17 - "Group was not done this morning due to a long TX team meeting and urgent need to see one particular patient." There was no documentation the patients were offered a make up group.

8/16/17 - PI # 2 did not attend group. There was no documentation why PI # 2 did not attend group, was encouraged to attend group or that an individual group was offered.

Written questions were submitted to Employee Identifier (EI) # 21, Director of Nursing, on 8/24/17 related to PI # 2 and group attendance and individual therapy. EI # 21 provided written responses as follows:

On 8/07/17 EI # 1, Psychiatrist and EI # 2, CRNP, always encourage patients to attend group. No response as why a make up group was not offered to PI # 2 was provided. EI # 21 wrote the counselors see the patient daily, however there is no individual therapy notes in the medical record.

On 8/08/17 treatment team started late and the last patient was not seen until late in the afternoon. No response provided as to why a make up group was not provided to the patients.

On 8/11/17 EI # 21 responded PI # 2 was evaluated and individually counseled by EI # 2 while a counselor was present. A review of the note did not document individual counseling per the care plan for PI # 2.

On 8/15/17 EI # 21 responded due to the high level of acuity of the 18 patients on the unit treatment team lasted most of the day and there was no additional time allowed during the shift to prepare and present an additional group meeting.

The hospital failed to provide group and individual therapy to PI # 2 per his care plan.



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3. PI # 3 was admitted to the facility 6/6/17 with diagnoses including Bipolar Mood Disorder and Suicidal Ideations. PI # 3 was an involuntary transfer from another facility.

Review of the Psychosocial Treatment Plan for PI # 3 revealed the following: attend a minimum of two groups daily, individual counseling and attend activity therapies daily.

Review of the Interdisciplinary Care Plan revealed expected outcomes and interventions as:

a) Patient will be engaged in an individual/group therapy to educate patient regarding illness and encourage recovery.

b) Family or significant others will be involved in treatment designed to provide education and increase understanding of the importance of significant others to recovery.

c) Patient will be assigned individual/group therapy appropriate treatment.

d) Staff will administer assigned therapeutic activities from treatment.

Review of the medical record (MR) revealed Group Counseling notes dated 6/7/17, 6/8/17, 6/9/17, and 6/12/17. Each note documented PI # 3 did not attend group. There was no documentation why PI # 3 did not attend group or documentation the staff encouraged him/her to attend.

There was no documentation of group therapy or activity on 6/10/17 or 6/11/17 (Saturday and Sunday).

There was no documentation in the MR of any additional therapies/groups/activities provided or offered to PI # 3 and no documentation the staff encouraged PI # 3 to attend scheduled therapies. There was no documentation individual counseling was offered.

PI 3 # was discharged 6/13/17 at 3:55 PM. There was no documentation PI # 3 received therapy during his/her 7 day hospitalization.

Written questions were submitted to EI # 21 on 8/23/17. On 8/24/17 EI # 21 provided written responses back related to whether PI # 3 a) was encouraged to attend group, b) was PI # 3 offered individual counseling, c) what other treatment modalities were available and d) what treatments were provided for PI # 3 on Saturday and Sunday. The responses were:

a) the physician and nurse practititioner as well as other staff always encourage patients to attend group and activities on a daily basis.

b) group therapy was offered multiple times in which PI # 3 did not attend, psychosocial evaluation completed individually with the patient, patient had problems with socialization with other patients and staff members due to illiteracy.

c) Monday - Friday daily devotional, exercise and PT (physical therapy), music therapy, and individual activities are offered.

d) Saturday daily devotional, music therapy, and individual activities are offered. Sunday a chaplain is present to lead the patients in devotions and any spiritual requests. Patients are allowed to have free time for socialization and visit with family and friends from 1:00 PM to 8:00 PM.

The hospital failed to provide group and individual therapy to PI # 3 per his/her care plan.



37268

4. PI # 4 was admitted to the facility 5/15/17 with diagnoses including Suicidal Ideations.

Review of the Interdisciplinary Care Plan dated 5/16/17 for PI # 4 revealed the following short term goals:

"... Patient will comply with unit rules as evidenced by participation in groups, ...Patient will participate in groups and other therapies 2 X (times) per day...

Expected Outcomes:

Patient will not experience complications of untreated withdrawal, ...Patient will be engaged in an individual/group therapy to educate patient regarding illness and encourage recovery..."

Review of the Nurse Group Note dated 5/16/17 revealed the following documentation: "There was no 11:00 AM group due to late, extended team meeting." The staff failed to offer and document the patient participation in individual/group therapy 2 X per day per patient's care plan.

Review of the Group Notes dated 5/17/17, 5/18/17, and 5/19/17 revealed PI # 4 attended one group counseling session each day. The staff failed to offer and document the patient participation in individual/group therapy 2 X per day per patient's care plan.

An Interview was conducted on 8/24/17 at 4:57 PM with EI # 21, Director of Nursing, who confirmed the above findings.

Based on review of video camera footage, facility policy, medical records, and interview with staff, it was determined the facility failed to ensure the staff followed the Alternating Rounding process per policy. This affected 8 of 15 medical records reviewed, including PI (Patient Identifier) # 14, # 10, # 11, # 15, # 12, #7, #6, and # 2. This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Facility Special Services Education and Staff Meeting
Effective Date: June 6 - June 7, 2017

"Suicide Education:

...5. Documentation

a. Suicide leveling Assessment Tool: This tool has been created to ask specific questions related to suicide or self-harm using a point system to determine the level of risk per patient. This assessment must be performed on admission and at a minimum of every 24 hours a day to reassess. However, if at any time the Nurse and/or MHT (Mental Health Technician) determine that the patient has had changes then the Suicide Leveling System should be done to assess for the need to increase the patient's level or need for 1 to 1 observation ...

Suicide Leveling System Assessment (New) and Documentation Process

1. New Process:

a. All patients will be assessed for suicidal ideations and precautionary measures by using the Suicide Leveling System Assessment Tool on admission and at a minimum of every 24 hours. This does not limit the need to reassess the patient more during your shift or as the patient's need changes throughout his/her stay.

b. Once the nurse finishes assessing the patient's suicide risk and completing the Suicide Leveling System Tool the nurse then assigns a level and informs the Physician (MD) or LIP (Licensed Independent Practitioner) of the need to increase the patient's observation status. After notification of the MD and/or LIP the nurse will inform the assigned MHT of the patient's observation status and of any increased observation (i.e. [example] One-on-One).

c. There are 3 different observation categories: 15 Minute Checks (Routine checks), 1:1 LOS (one-to-one in line of sight) and 1:1 WAL (one-to-one within arm's length).

d. Policy AHW.600.0020 provided

Additional Alternating Rounding Process

1. Assignment of Alternating Rounds and Documentation

a. The Charge Nurse will assign this task to a Nurse and/or MHT every shift.

b. If one of the assigned staff members has to leave the unit (i.e. lunch or break) the Nurse and/or MHT will give the receiving Nurse/MHT a concise report on his/her patient and turn care of this patient over to this employee until they return to the unit. Once the Nurse/MHT returns to the unit this employee will give a complete and concise report to him/her and relinquish care back to the assigned employee.

c. The employee assigned to this rounding process will do alternating rounds at different times between the Q (Every) 15 minute checks done by the assigned MHT. This means that this employee may do a rounding time on a patient at 0905, 0908 or 0911 between the 0900-0915 routine. By adding this alternating rounding assignment will feel like the patient will not be able to lean the routine of the unit regards to rounding and has an additional staff member monitoring all of the patients for safety.

Policy title: Patient Rounds

Revised: 7/05/17

It is the policy of the Special Services Unit (psychiatric unit) to provide a safe environment for the patients by conducting patient rounds.

Purpose: To ensure consistent and continuous surveillance of patients and the physical building and to assess the safety of each patient and the physical unit routinely.

Procedure: Patient rounds may be done by unit personnel to include visualization of each patient. Rounds shall be made at least every 15 minutes per 24 hour day. Alternating rounds will be done on each patient between the 15 minute rounding times, but not on the fifteen minute time frame. Example: Normal 15 minute rounds are done 0800 and 0815 the alternating rounds will be done at no specific times. For example, close observation rounds are made on every 15 minute increment. The alternating rounds are to be performed by an assigned Nurse / Mental Health Tech every shift that will do a non-scheduled round between every 15 minute close observation round. Environmental safety rounds on all rooms and unit will be done on each shift.

Policy title: Close Observation/ 1:1 Observation of Patients

Patients admitted to the psychiatric unit are placed on suicidal/homicidal precautions and will be monitored under close observation. Patients who are actively suicidal or homicidal and score a level 1 / imminent risk on the suicide assessment will be placed on 1:1 line of sight (LOS) or 1:1 within arm's reach (WAL) according to the physician's order. Patients that score a Level 2 / moderate risk may be upgraded and placed on 1:1 LOS or 1:1 WAL according to physician's order.

Procedure:

Close Observation
A. All patients shall be placed on Close Observation for the duration of the hospitalization.
1. Close observation require that staff monitor the patient by direct visual contact every fifteen minutes which will be documented on an Observation Log sheet.

1:1 Line of Sight (LOS)
A. 1:1 Line of Sight requires that staff constantly monitor the patient with the line of sight observation and document this observation every 15 minutes on the Observation Log sheet.

1:1 Within Arm's Reach (WAL)
A. 1:1 Within arm's reach requires that staff remain within arm's length of the patient at all times and document this observation every 15 minutes on the Observation Log sheet.

**********

1. PI # 14 was admitted to the facility's psychiatric unit on 8/17/17 with diagnoses including Suicidal Ideations.

Review of the MHT rounding Log (routine checks) and the Alternating Nursing/MHT Rounding Log dated 8/19/17 revealed the staff documented rounds at the same time at: 1300, 1715, 0300, 0315, 0330, 0345, 0400, 0415, 0445, 0500, 0515, 0530, and 0715. The staff did not follow the facility procedure for alternating rounds.

Review of the MHT rounding Log and the Alternating Nursing/MHT Rounding Log dated 8/20/17 revealed the staff documented rounds at the same time at: 1700, 1915, 1930, 2000, 2015, 2030, 2045, 2100, 2115, 2130, 2145, 2200, 2215, 2230, 2245, 2300, 2315, 2330, 2345, 0000, 0015, 0030, 0045, 0100, 0230, 0445, 0500, 0615, 0700, 0715, 0730, and 0900. The staff did not follow the facility procedure for alternating rounds.

Review of the MHT rounding Log and the Alternating Nursing/MHT Rounding Log dated 8/21/17 revealed the staff documented rounds at the same time at: 0930, 0945, 1000, 1015, 1030, 1045, 1100, 1115, 1130, 1145, 1200, 1215, 1230, 1245, 1345, 1400, 1415, 1430, 1445, 1500, 1515, 1530, 1545, 1600, 1615, 1630, 1645, 1700, 1715, 1730, 1745, 1800, 1815, 1830, 1845, 1900, 0745, 0800, 0815, 0830, 0845, and 0900. The staff did not follow the facility procedure for alternating rounds.

2. PI # 10 was admitted to the facility's psychiatric unit on 8/21/17 with diagnoses including Suicidal Ideations.

Review of the MHT rounding Log and the Alternating Nursing/MHT Rounding Log dated 8/21/17 revealed the staff documented rounds at the same time at: 2000, 2015, 2030, 2045, 2100, 2115, 2145, 2200, 2215, 2230, 2245, 2300, 2315, 2330, 2345, 0000, 0015, 0030, 0045, 0100, 0115, 0130,0145, 0200, 0215, 0745, and 0815. The staff did not follow the facility procedure for alternating rounds.

3. PI # 11 was admitted to the facility's psychiatric unit on 8/23/17 with diagnoses including Suicidal Ideations.

Review of the MHT rounding Log and the Alternating Nursing/MHT Rounding Log dated 8/23/17 revealed the staff documented rounds at the same time at: 1030, 1045, 1200, 1215, 1245, 1315, 1400, 0630, 0645, 0700, 0715 and 0745. The staff did not follow the facility procedure for alternating rounds.

4. PI # 15 was admitted to the facility's psychiatric unit on 8/23/17 with diagnoses including Suicidal Ideations.

Review of the MHT rounding Log and the Alternating Nursing/MHT Rounding Log dated 8/23/17 revealed the staff documented rounds at the same time at: 1300, 1315, 1415, 0630, 0645, 0700, 0715, 0730, 0745, 0815, and 0845. The staff did not follow the facility procedure for alternating rounds.

An Interview was conducted on 8/24/17 at 4:10 PM with Employee Identifier (EI) # 11, Registered Nurse (RN), Psychiatric Unit Manager, who confirmed the above findings.



36271

5. PI # 12 was admitted to the facility 8/18/17 with diagnoses including Schizophrenia.

Review of the Alternate Nurse/MHT (Mental Health Technician) Rounding Log revealed the alternating rounding tool documented alternating observations were completed at the same time as the scheduled observations for the following dates and times:

8/20/17: 7:15 PM to 1:00 AM

8/21/17: 9:30 AM to 12:45 PM and 1:45 PM to 7:00 PM and 7:45 AM to 9:00 AM

8/22/17: 3:45 PM to 5:45 PM

6. PI # 7 was admitted to the facility 8/1717 with diagnoses including Depression.

Review of the Alternate Nurse/MHT Rounding Log revealed the alternating rounding tool documented alternating observations were completed at the same time as the scheduled observations for the following dates and times:

8/22/17: 4:00 PM to 7:45 PM

7. PI # 6 was admitted to the facility with diagnoses including Depression.

Review of the Alternate Nurse/MHT Rounding Log revealed the alternating rounding tool documented alternating observations were completed at the same time as the scheduled observations for the following dates and times:

8/20/17: 8:45 PM to 10:15 PM and 7:00 AM to 8:00 AM

In an interview conducted 8/24/17 at 3:20 PM with EI # 11, Registered Nurse Psychiatric Unit Manager, EI # 11 was asked what is the expectation of staff when completing the rounding and alternate rounding tools? The resonse was always do it completely - no blanks - round as they should - go in the room and lay eyes on the patient - sign everything - make sure they are thorough. Alternating rounds the same...do it at different times from the regular times.


21056


8. PI # 2 was admitted to the hospital on 8/04/17 for depression and suicidal ideation.

A review of the Mental Health Tech Rounding Log, used by MHT staff assigned to observe patients and document on the patient every 15 minutes was reviewed. On 8/21/17 at 9:00 PM, EI # 24, MHT, documented PI # 2 was in his room quietly resting. Review of the video camera footage at 9:00 PM did not show EI # 24 observed PI # 2 at this time.

After the incident with PI # 1, patient that successfully committed suicide in the psychiatric unit, alternating rounds were implemented by the hospital in an effort to keep patients from learning the routine every 15 minute checks that staff was suppose to complete. The process implemented was for assigned staff to complete the every 15 minute observations on the quarter hour schedule and then an alternate staff person was assigned to complete observations of the patient at times other than the quarter hour observations. A review of the Alternating Nurse / MHT Rounding Log, where staff were to document observations at times other than the quarter hour observations, for PI # 2 was reviewed. The alternating rounding tool documented alternating observations were completed at the same time as the scheduled observations for the following dates and times:

8/05/17: from 9:00 AM to 9:30 AM and 3:00 PM to 7:15 PM and 7:15 AM to 9:00 AM (the next morning)
8/06/17: from 9:00 AM to 1:15 AM (the next morning) and 2:00 AM to 4:30 AM and 5:15 AM to 6:00 AM and 6:15 AM to 7:30 AM.
8/10/17: from 7:00 PM to 6:00 AM (the next morning) and 6:45 AM to 7:15 AM and 7:45 AM to 8:15 AM
8/11/17: from 6:30 PM to 7:00 PM and 7:30 PM to 10:15 PM
8/12/17: from 10:00 AM to 10:30 AM and 8:30 PM to 9:15 PM and 10:00 PM to 6:30 AM (the next morning)
8/13/17: from 10:15 AM to 12:45 PM and 1:00 PM to 2:00 PM and 4:15 PM to 7:15 PM
8/14/17: from 9:00 AM to 9:45 AM and 7:30 PM to 9:00 PM
8/15/17: from 5:00 PM to 7:15 PM and 9:00 PM to 10:00 PM and 2:30 AM to 4:30 AM
8/16/17: from 9:45 AM to 3:00 PM
8/18/17: from 7:15 PM to 11:45 PM
8/19/17: from 2:45 AM to 5:30 AM
8/20/17: from 7:15 PM to 1:00 AM on 8/21/17
8/21/17: from 9:30 AM to 7:00 PM

On 8/24/17, EI # 21, Director of Nursing was given written questions related to the alternate rounding times being documented at the same time as the every 15 minute checks. EI # 21 provided a written response that staff was educated on the new rounding process and the employee involved was hired after the incident with PI # 1 and initial education that was provided to staff.

On 8/24/17 at 4:15 PM, EI # 21, Director of Nursing (DON) was interviewed. EI # 21 was asked what the expectation of staff was when completing the round tool. EI # 21 stated staff was to monitor patients closely, chart appropriately and put their eyes on the patients. Staff were to go in the room and check the patient to make sure the patient was actually there and alive. EI # 21 was asked what is different now since the incident with PI # 1. EI # 21 stated bathroom door knobs were removed from all bathroom doors, extra staff were placed on the unit the day of the incident, the suicide leveling process was re-done, alternate rounding was put in place and environmental roundings were to be done each day. EI # 21 was asked who is responsible for assuring staff are following the new procedures and she (EI # 21) stated EI # 11 and then herself.

Staff failed to follow the alternating rounding process on PI # 2 and the hospital failed to assure new staff was educated and following the alternate rounding process.

Based on review of medical records and interviews with staff it was determined the facility failed to ensure the medical record for each patient was complete and accurate for 1 of 15 records reviewed, Patient Identifier (PI) # 1 and had the potential to affect all patients treated in the psychiatric unit.

Findings include:

Patient Identifier (PI) # 1 was admitted to the hospital on 6/15/17 after attempts in the community and while a patient at Hospital # 1 to commit suicide by hanging.

A review of the close observation flowsheet dated 6/19/17 was completed. From 4:15 PM until 7:30 PM hospital Employee Identifier (EI) # 20, Mental Health Tech, documented on the close observation flowsheet her monitoring of PI # 1 every 15 minutes. The medical record also contained a one to one flowsheet for PI # 1 dated 6/19/17. From 4:16 PM until 7:00 PM EI # 25, Mental Health Tech, documented on the one to one flowsheet his monitoring of PI # 1 every 15 minutes.

Written questions were given to EI # 21, Director of Nursing, on 8/23/17 asking why there were two different monitoring flowsheets completed by two different Mental Health Techs for the same day and same time period. EI # 21 provided written responses back stating the close observation documentation form should have been stopped at 4:15 PM with the last documentation entry at 4:00 PM.

Staff failed to document on the correct monitoring form for PI # 1 and failed to identify why two separate MHTs were documenting on the same patient during the same time periods. There was no order in the medical record for PI # 1 to be placed on two to one observation status.


36271

Based on observation, review of the physical environment rounding tool and interviews, invoices and quotes for renovation work, the hospital failed to provide and maintain a safe environment for patients admitted to the psychiatric unit. The governing body failed to complete psychiatric unit renovations timely to assure the physical environment was safe for patients. In addition, the hospital failed to assure the physical environment was free of potential ligature risk and assure the physical environment was clean and in good repair. This failure allow Patient Identifier (PI) # 1 to use a bathroom door knob to tie a piece of a patient gown around and successfully commit suicide. In addition, Patient Identifier # 2 was able to remove screws from a plexiglass window covering and elope from the facility. These failures had the potential to affect all patients served in the psychiatric unit.

During the survey hospital staff provided documentation of measures put in place to prevent the potential for future harm to patients.

Finding include:

Refer to A 43, A 115 and A 724.

Based on observation, review of the physical environment rounding tool and interviews, invoices and quotes for renovation work, the hospital failed to provide and maintain a safe environment for patients admitted to the psychiatric unit. The governing body failed to complete psychiatric unit renovations timely to assure the physical environment was safe for patients. In addition, the hospital failed to assure the physical environment was free of potential ligature risk and assure the physical environment was clean and in good repair. This failure allow Patient Identifier (PI) # 1 to use a bathroom door knob to tie a piece of a patient gown around and successfully commit suicide. In addition, Patient Identifier # 2 was able to remove screws from a plexiglass window covering and elope from the facility. These failures had the potential to affect all patients served in the psychiatric unit.

During the survey hospital staff provided documentation of measures put in place to prevent the potential for future harm to patients.

Finding include:

Refer to A 43 and A 115 for findings.

During a tour of the hospital on 8/22/17 at 8:50 AM, with Employee Identifier (EI) # 23, Chief Executive Office (CEO), the surveyors observed the following environmental hazards:

Shower room on unit: only contained one dimly lit light that had a cracked cover. There was rust around the metal door frame inside the shower room.

Room 172: mattress cover on bed had a tear that exposed foam.

Room: 170 (Room PI # 1 was assigned to at the time of his death): two metal clips used to hold shelving in place were located inside one of the wooden cabinets that was visible and could easily be removed; the wooden door to the room had a square hole in the center of it where a glass pane had been, there was no covering over the hole; chipped paint was observed on the wall over the built in cabinet; no window curtain was up to provide for patient privacy; bathroom light was not working;

Room 166: rust around the bathroom door frame and wall unit in the bathroom.

Room 164: rust around the bathroom door frame and on wall unit in the bathroom; there was no light in the shower area of the bathroom.

Room 162: rust around the bathroom door frame.

Room 160: rust around the bathroom door frame; shower area had a used dry wash cloth that had not been removed.

On 8/23/17 at 3:20 PM, survey staff along with EI # 21, CEO, EI # 22, Facility Manager and EI # 11, Registered Nurse Psychiatric Unit Manager, all observed patient room 170, where Patient Indentifer # 2 eloped on the night of 8/21/17. The plexiglass had been replaced by EI # 22 the night PI # 2 eloped with non-tamper proof screws. EI # 22 stated he was going to order the tamper proof screws and when they came in he would secure the plexiglass with the approved screws. A current patient was placed in the room on 8/22/17, the day after PI # 2 eloped and the plexiglass secured with non-tamper proof screws.

On 8/23/17 at 3:25 PM, survey staff along with EI # 1, CEO, EI # 22, Facility Manager and EI # 11, Registered Nurse Psychiatric Unit Manager, all observed an empty patient room, number 165. During this room observation survey staff was able to pull from the wall the flush mounted shower head enough to place a finger behind the fixture. Room 165 had exposed toilet plumbing that was high enough a patient could use the plumbing as a potential ligature support. EI # 11 was going to have a Mental Health psychiatric unit staff person conduct a thorough tour of the entire psychiatric unit to identify any other potential safety issues immediately and submit any needed work orders to EI # 22, Facility Manager.

On 8/24/17 survey staff was provided a copy of the Mental Health psychiatric until staff persons findings from 8/23/17 related to the physical environment rounding. The following concerns were identified:

Room 160: beds not secured to the floor and can be moved; wall plugs open with no cover; plumbing on toilet possible hazard; metal rails on walls can be bent and broken off wall; paint chipping in doorway, soap dispenser cover loose; light switch not working.

Immediate corrective actions taken: broken brackets on the beds were replaced; electricity was disconnected to wall plug; enclosure built to place around toilet plumbing; metal rails were removed; re-painting wall; removed soap dispenser; light was removed - electricity had been turned off to switch.

Room 161: floor tiles peeling in corner; ceiling tile crooked; light switch not working / light was removed; vent had wire mesh; shower in room does not work; plumbing on toilet possible hazard; beds not secured to the floor and can be moved.

Immediate corrective actions taken: clear sealant placed as a temporary fix; ceiling tile on order 8/28/17 expected; light switch electricity disconnected; patient is using the common shower on the hall; enclosure built to place around toilet plumbing - completion date of 9/01/17; broken brackets on the beds were replaced.

Room 162: light switch not working; metal railings on wall; ceiling tiles chipping; no cover on toilet paper tissue dispenser; show wall cracked; counter cracked; cabinet peeling; lights dirty; vent over toilet covered in dust; door molding rusted; toilet plumbing cracked; wall plugs not covered; floor molding not secured; beds not secured and can be moved; cold water in shower.

Immediate corrective actions taken: light removed and electricity disconnected; removed metal railings on wall; ceiling tile ordered - expected 8/28/17; silicone placed in cracked shower wall; glued and caulked cracked counter; lights and vent cover cleaned; cement compound ordered to place around door moldings - expect 9/01/17; secured floor molding and beds.

Room 163: tile not secure; metal rails on walls; light switch not working; shower in bathroom not working; shower tiles were missing; rusty heater vent in bathroom; space between counter and cabinet; damage to wall causing exposed concrete and metal; floor tiles missing.

Immediate corrective actions taken: tile sealant placed; metal rails were removed; electricity disconnected and light removed 8/25/17; ceramic tiles were ordered (no expect date listed); painted heater vent in bathroom; covered space with a strip and secured with tamper resistant screws; damaged wall was filled with rock tight to cover it up 8/28/17; baseboard molding ordered - expected 9/01/17.

Room 164: cracked tile, plumbing on toilet possible hazard; light switch not working; metal rail on wall; beds not secured to floor; wall plugs were not covered; rust in door way of bathroom and on wall heater in bathroom; no cover over the tissue dispenser; room vent was dirty and loose.

Immediate corrective actions taken: cracked tile replace - expected 9/01/17; building plumbing enclosure for toilet plumbing; electricity disconnected to light switch; metal rail was removed; beds were secured; painting doorway and heater; ordered new tissue dispenser; vent cleaned and screws tightened.

Room 165: no cover on tissue dispenser; no wall plug cover; cracked tile in front of sink; plumbing on toilet possible hazard; beds not secured.

Immediate corrective actions taken: new tissue dispenser ordered (no expect date); electricity disconnected from wall plug; tile replaced; building plumbing enclosure for toilet plumbing;
beds secured.

Room 166: light switch not working; broken light fixture above the patient bed; metal rails on wall; counter cover not secured; no cover on tissue dispenser; broken light fixture in bathroom; cracked tile in bathroom; rust damage door molding in bathroom and bathroom heater vent; paint peeling; mattress too long for the bed frame.

Immediate corrective actions taken: electricity disconnected from switch; repaired broken light fixture above bed; metal rails removed; counter top secured; ordered new tissue dispenser (no expect date); broken light fixture in bathroom repaired; rock tight placed on exposed rust; in process of painting (no expected completion date listed); new mattress ordered for bed 8/28/17 received.

Room 170: rust on bathroom door molding; floor modeling not secured; two cabinet drawers missing leaving a potential for ligature; no curtain in room; cracked tiles; wall plugs not covered.

Immediate corrective actions taken: painting in process for door molding; ordered baseboards on 8/28/17; removed drawer/assessed cabinet for hanging points; replaced cracked tiles; electricity disconnected to plugs.

Common shower on hall: cracked tiles; rust in doorway; ceiling paint chipped and damaged.

Immediate corrective actions: ordered tile 8/28/17; painting in process.

Common hallway on unit: molding missing in some areas and coming up.

Immediate corrective actions taken: baseboards ordered 8/28/17.

Room 171: light switches not working; molding not secured; cracked tile; concrete exposed; ceiling tile damaged; vent in bathroom rusty and not secured; hole in tile; uncovered wall plugs; no cover on tissue dispenser.

Immediate corrective actions taken: electricity disconnected; baseboards ordered 8/28/17; tile caulked to cover cracks and concrete; ordered ceiling tile 8/28/17; vent painted and secured with screws; replaced tile that had a hole; new tissue dispenser ordered 8/28/17.

Room 172: hole over light fixture; holes in wall; cracked tile; dirty vent in bathroom; mold on door frame; peeling paint; cabinet drawer missing potential area for ligature; no window curtains; wood cabinets peeling.

Immediate corrective actions taken: covered hole over light fixture; caulked tile that was cracked; cleaned dirty vent in bathroom and door frame with mold; in process of painting; cabinet assessed for ligature and removed all metal parts; curtains ordered; wood cabinet glued and caulked for temporary fix.

On 8/24/17 at 7:58 AM, a tour of the Psychiatric Unit was conducted and the surveyors observed the following environmental hazards:

Room 161: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 162: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

The bathroom vent in the ceiling was missing a screw and dirty (dust buildup); the door jam to the bathroom was damaged/rotten which creates an unsafe environment for patients.

Room 163: The shower light would not turn on when the surveyor flipped the switch; the toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 164: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 165: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 166: The windows in the room did not have tamper resistant screws; the toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 170: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 171: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

Room 172: The toilet plumbing was exposed and high enough a patient could use the plumbing as a potential ligature support which creates an unsafe environment for patients.

There were several bathrooms with double latch striker plates installed; the latches are large enough for patients to thread items through the opening which creates an unsafe environment for patients.

There were frail and cracked bathroom light fixtures throughout the unit that creates an unsafe environment for patients.

There was a torn gown in the clean gown inventory located in the hallway cabinet that a patient could tear and use for ligature which creates a potential unsafe environment for patients.

There were missing curtains in several of the patient rooms to provide privacy.

An interview was conducted on 8/24/17 at 8:25 AM with EI # 23, and EI # 22, who verified the above findings.

On 8/24/17 at 4:15 PM, EI # 21, Director of Nursing (DON) was interviewed. EI # 21 was asked about environmental rounds and the follow up that was to be completed for items that were identified by staff as a concern or potential for harm. EI # 21 stated staff should report issues to the charge nurse and the charge nurse would make a decision if immediate actions were needed by maintenance. EI # 21 stated EI # 11 and EI # 22, Facility Manager, would be responsible for following up to be sure work orders were completed.

Employee Identifier # 1, CEO, provided an invoice to the surveyor dated 8/23/17 showing where 6 new bed mattresses had been ordered. This invoice was dated after the arrival of surveyors. In addition, EI # 1 also provided a price quote for tamper proof screws that was dated 8/24/17. This invoice was dated after arrival of the surveyors.

Employee Identifier # 1, CEO, provided information related to hospital renovations that were discussed related to the psychiatric unit. Two separate quotes were obtained for the work, but none of the purposed renovations have been started for the psychiatric unit.

Estimate one dated 2/07/17 listed the following items as part of the renovations:

a. plumbing repair/replace
b. heating and air conditioning
c. sprinkler
d. electrical
e. new bathroom
f. new seclusion room
g. new ADA bathrooms
h. refurbish all patient rooms
i. refurbish corridors

Estimate two dated 4/24/17 listed the following items as part of the renovations:

a. install new floors
b. install new ceiling grid, insulation and tile
c. install new LED lighting fixtures
d. replace most patient doors and hardware
e. replace all bathrooms including tile and plumbing fixtures
f. replace door frames that have rotted out primarily in wet conditions
g. update electrical system
h. upgrade sprinkler system
i. new painting

Interviews

On 8/23/17 at 9:45 AM, an interview was conducted with EI # 2, Certified Registered Nurse Practitioner (CRNP). EI # 2 stated the psychiatric unit was suppose to be updated back in 2012, but nothing has been done yet (no renovation work). EI # 2 stated some rooms do not have adequate lighting and EI # 2 has told staff they would not accept this room for their own mother.

On 8/23/17 at 12:38 PM, EI # 11, Registered Nurse Psychiatric Unit Manager, was interviewed related to the incident with PI # 1. EI # 11 was asked what is done differently now since the incident happened and stated the policy for Mental Health Techs (MHT) rounding was change and now alternate rounding was to be done. The suicide leveling system was changed and is now done daily, which identifies patients at high risk for suicide with a numerical scale. Depending on where the patient scores determines if the patient's status should change from every 15 minute rounds to a higher 1:1 level of observation. EI # 11 stated there are more patients now on a 1:1 level of observation since the implementation of the suicide leveling system. EI # 11 stated bathroom door knobs were removed and other identified items that might be a potential for harm. EI # 11 stated until the psychiatric unit is remodeled the staff try to identify potential problems and that she is trying to increase the staffing on the unit. EI # 11 was asked when the renovations would start in the psychiatric unit and stated around Christmas. EI # 11 confirmed MHTs were to complete the environment rounds and checks and that she would look over them.

On 8/24/17 at 2:40 PM, Employee Identifier (EI) # 23, Chief Executive Officer (CEO), was interviewed. During the interview EI # 23 was asked how long the hospital had been in discussions about renovations to the psychiatric unit and stated about nine months was when things got started. EI # 23 was asked if the hospital had a current contract to complete renovations in the psychiatric unit and stated there was a contract with an architect for plans and a bid was received, but the hospital was waiting to see if they could obtain four additional beds to increase the number of psychiatric beds in the unit. EI # 23 was asked what immediate measures were put in place after the incident with PI # 1, who successfully committed suicide while he was a patient on the psychiatric unit. EI # 23 stated a root cause analysis was conducted, bathroom door knobs were removed, a plan was put in place for different rounding (the alternate rounding procedure), clarified definitions for all staff on meaning of 1:1 observations verses within arm's reach, staff education, documentation reviews, video reviews, possible placement of a security guard on the unit, keep closer watch on linen kept in the patient rooms, and changes to the activities program to keep the patients busy and offer patients more options. EI # 23 stated the charge nurse, psychiatric unit manager and Director of Nursing was responsible for assuring these changes were implemented and followed by staff. EI # 23 was asked what immediate measures were put in place after the incident with PI # 2, who successfully eloped from the hospital. EI # 23 stated maintenance came the same night and secured the window PI # 2 eloped from, the roommate in the room with PI # 2 was moved to a new room, staff were placed by the room door and chairs were placed in front of the room door to keep other patients from entering the room, and the outside window glass that was broken was replaced. EI # 23 stated in addition, the hospital is looking at using different thermostat covers without a metal frame and that the ceiling was looked at to make sure it was safe. EI # 23 stated the maintenance staff, psychiatric unit nurse manager and staff assigned for completing patient rounds are responsible for assuring these measures are followed. EI # 23 stated the hospital was still completing the root cause analysis at the time of the survey.

On 8/24/17 at 3:20 PM, EI # 11, Registered Nurse Psychiatric Unit Manager, was interviewed a second time. EI # 11 was asked how long the hospital had been discussing renovations to the psychiatric unit. EI # 11 stated since she returned to work at the hospital in April 2017 she knew there were discussions, but nothing had been done yet. EI # 11 was asked what the expectation was of staff when completing the rounding tool. EI # 11 stated staff should always complete the tool, leave no blanks, go in the room and lay eyes on the patient. EI # 11 stated the alternate rounding process needed to be ironed out, but the expectation would be the same as for the every 15 minute rounding. If staff get tired or have a lack of focus they should let someone know. EI # 11 confirmed the alternate rounding should be completed at different times than the every 15 minute rounding. EI # 11 was asked about the environment rounds and the follow up that was to be completed for items that were identified by staff as a concern or potential for harm. EI # 11 stated staff should place a work order, notify the charge nurse on the unit and that she (EI # 11) should follow up to assure the work order was completed. EI # 11 was asked what measures were put in place after the incident with PI # 2, the patient that successfully eloped. EI # 11 stated the glass in the room was fixed, additional screws were placed in the window that was removed, and the roommate was moved to a different room.

On 8/24/17 at 4:15 PM, EI # 21, Director of Nursing (DON) was interviewed. EI # 21 was asked how long the hospital had been discussing renovations to the psychiatric unit. EI # 21 stated for at least one and one half years. EI # 21 stated discussions started when issues were found, then put on hold until a decision could be made about adding beds to the psychiatric unit. EI # 21 stated she knew a contract with an architect had been made, but no work had been started on the renovations. EI # 21 was asked about environmental rounds and the follow up that was to be completed for items that were identified by staff as a concern or potential for harm. EI # 21 stated staff should report issues to the charge nurse and the charge nurse would make a decision if immediate actions were needed by maintenance. EI # 21 stated EI # 11 and EI # 22, Facility Manager, would be responsible for following up to be sure work orders were completed. EI # 21 was asked what the expectation of staff was when completing the round tool. EI # 21 stated staff was to monitor patients closely, chart appropriately and put their eyes on the patients. Staff were to go in the room and check the patient to make sure the patient was actually there and alive. EI # 21 was asked what is different now since the incident with PI # 1. EI # 21 stated bathroom door knobs were removed from all bathroom doors, extra staff were placed on the unit the day of the incident, the suicide leveling process was re-done, alternate rounding was put in place and environmental roundings were to be done each day. EI # 21 was asked who is responsible for assuring staff are following the new procedures and she (EI # 21) stated EI # 11 and then herself.


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