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Based on observation, record review, and interview staff failed to ensure a safe environment for behavioral health patients in 9 of 9 patient rooms observed (room 320, 321, 322, 317, 331, 211, 212, 208, 219) 1 of 1 shower room, and 5 of 5 staff interviews (A, B, G, O, Q). This could potentially impact all 24 patients receiving treatment at this behavioral health facility.

Findings Include:

Staff failed to maintain a safe environment minimizing potential risk for suicide and self-injurious behaviors. See tag A144

The impact of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility.

Based on observation, record review, and interview staff failed to ensure a safe environment for behavioral health patients in 9 of 9 patient rooms observed (room 320, 321, 322, 317, 331, 211, 212, 208, 219) 1 of 1 shower room, and 5 of 5 staff interviews (A, B, G, O, Q). This could potentially impact all 24 patients receiving treatment at this behavioral health facility.

Findings Include:

Observations on 3/11/2016:

During tour of Behavioral Health facility beginning at 1:00 PM with Nurse Manager "B" and Clinical Therapist "C", observed 5 patient rooms on the adult floor (3 york), 3 patient rooms on the children/adolescent unit (2 york), and shower room. Observations of patient rooms revealed the following safety risks:

-Electrical outlets on walls (approximately 4 feet off the ground) in and outside of patient bathrooms are all covered with metal boxes; the metal boxes are secured with screws and protrude out from the wall approximately 1 inch. There is a 1/4 inch gap between the outlet plate and metal box, allowing for a ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk.

-Metal paper towel dispensers (attached to wall above sink) located in patient bathrooms contain sharp corners allowing potential for harm for patients with self injurious behaviors and/or suicide risk.

-Door handle housing unit (approximately 3 feet off the ground) on the inside and outside of patient's bathrooms protrudes approximately a 1 and 1/2 inches off the door at a 90 degree angle, allowing for a ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk.

-Call light in shower room protrudes approximately 2 and 1/2 inches off the wall and is secured in place with screws allowing for ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk. Per interview with Nurse Manager "B" at the time of the tour, "B" stated staff stand outside of shower room when patients are showering and patients are given towels to use inside the shower room.

Per observations on 3/15/16 beginning at 1:30 PM, Medical Doctor "Q" was able to rip the elastic out of a fitted sheet used on the behavioral health units and create a ligature. "Q" wrapped the ligature around the door handle housing unit and attached other end around "Q's" neck for the purpose of demonstration of ways patients could potentially attempt suicide. "Q" was able to apply enough pressure to neck to cut off oxygen supply without the ligature slipping off the door handle housing unit. Per interview with "Q" at the time of demonstration, "Q" stated, "I guess this would work." "Q" stated "Q" was not aware fitted sheets with elastic were still being used on the units. Director of Quality "R" and Director of Risk Management "G" (both present at the time of observation) and Medical Doctor "Q" were asked to attempt to rip a flat sheet and demonstrate the same situation. Staff found a flat sheet and identified a hole/defect in the flat sheet, "R" and "Q" were able to rip the flat sheet and create a ligature. "Q" wrapped the ripped piece of flat sheet around the door handle housing unit and attached other end to "Q's" neck and again was able to apply enough pressure to neck to cut off oxygen supply without the ligature slipping off the door handle housing unit.

Per interview with Environmental Services Manager "O" on 3/15/16 beginning at 2:30 PM, "O" stated housekeeping staff should be inspecting all sheets and ensuring sheets do not have holes or defects that could allow patients the ability to tear sheets.

Review of Pt 5's medical record on 3/14/16 beginning at 2:40 PM, revealed Pt 5 was admitted on 11/13/15 at 1:45 PM to the behavioral health unit status post a suicide attempt. Pt 5 was placed on suicide precautions level 2.

Per policy titled, "Suicide Assessment, Management and Precautions" last reviewed 6/15, Level 2 suicide precautions require that, "the patient is checked every 15 minutes" and that "certain objects may be removed from the patients room to provide safety of the patient and others".

Per facility occurrence report, on 11/17/15 documentation stated the following; "Writer found pt (Pt 5) sitting in shower, not responding to writer, pt's face was blue. Writer saw a white piece of cloth wrapped around pt's neck...writer was able to quickly unwrap cloth from pt's neck and undo two knots."

Per facility occurrence report, on 11/24/15 documentation stated the following; "...pt was found under the blanket with gauze wrapped around (Pt 5's) neck. pt's face was blue."

Per interview with Administrative Director "A" and Director of Risk Management "G" on 3/14/16 beginning at 10:30 AM, Pt 5 used a piece of a ripped towel to wrap around Pt 5's neck in both suicide attempts. "A" stated Pt 5 was still allowed unsupervised access to towels even after Pt 5 was found with a piece of towel wrapped around neck during the first suicide attempt on 11/17/15. "A" stated all patients are given towels when taking a shower, staff do not track and monitor towel usage. Patients and/or staff can return the towels to the dirty laundry bin. Per "A" there is no policy and procedure on the use of towels among patients with self injurious behaviors and/or suicidal ideation's.

Based on record review and interview staff failed to ensure all adverse patient events are investigated, analyzed for causes, and meaningful preventative actions implemented in 2 of 2 occurrence reports reviewed (Pt 5; 11/17/2015, 11/24/15). This could potentially impact all 24 patients receiving treatment at this behavioral health facility.


Findings Include:

Review of policy and procedure titled, "Reporting Patient/Visitor Occurrences" effective 4/1/2015 states the following:

-The online Patient/Visitor Occurrence Report form is to be completed for all occurrences with actual or potential injury to patients and visitors.

-Any medical device equipment of supplies involved in the occurrence must be removed, labeled as needing inspection and released to Clinical Engineering or Risk Management who will sequester the equipment/supplies until the investigation is completed.

- The director/manager/designee of the department is responsible for initiating investigative action, follow-up of all occurrences, and tracking and trending of all occurrences.

- Risk Management will do a thorough investigation of all serious patient occurrences. If the event is deemed a sentinel event, appropriate individuals will be brought together to discuss circumstances surrounding the event and appropriate follow-up. A Root Cause Analysis will be initiated for all Sentinel Events and Critical Events.



Review of Occurrence Report documentation on 11/24/15 showed the following, "Writer found pt (Pt 5) sitting in shower, not responding to writer, pt's face was blue. Writer saw a white piece of cloth wrapped around pt's neck...writer was able to quickly unwrap cloth from pt's neck and undo two knots."

Review of Occurrence Report documentation on 11/24/15 showed the following; "...pt (Pt 5) was found under the blanket with gauze wrapped around (Pt 5's) neck, pt's face was blue."

Per review of Pt 5's 11/17/15 and 11/24/15 Occurrence Reports, under the category "Action Steps" documentation for both dates states, "Appropriate immediate interventions instituted. RCA (root cause analysis) completed."

Review of Pt 5's RCA shows suicide attempts on 11/17/15 and 11/24/15 were combined under one root cause analysis and not investigated separately. RCA was not completed until 12/16/2015 almost 1 month after the first occurrence. RCA did not address Pt 5's access to towels despite towels being used in both suicide attempts.

Per interview with Administrative Director "A" and Director of Risk Management "G" on 3/14/16 beginning at 10:30 AM, Pt 5 used a piece of a ripped towel to wrap around Pt 5's neck on 11/17/15 and then again 7 days later on 11/24/15. "A" stated Pt 5 was still allowed unsupervised access to towels even after Pt 5 was found with a piece of towel wrapped around neck during the first suicide attempt on 11/17/15. "A" and "G" were unable to provide documentation of an immediate investigation into both separate incidents and evidence of developing a meaningful action plan to prevent this situation from reoccurring. "A" and "G" stated staff did not include Pt 5's access to towels as a part of the action plan. "A" stated, suicide attempt follow-up and investigation "should be immediate".

Per review of policy and procedure titled, "Reporting Patient/Visitor Occurrences" effective 4/1/2015, there is no documentation of a time frame for investigations into patient adverse occurrences.

Based on record review and interview staff failed to ensure nursing staff evaluate patient care needs, update plan of care with individualized goals and document interventions in response to change in patient condition in 2 of 10 patient records reviewed (Pt 1, 5). This deficient practice can potentially impact all 24 patients receiving treatment at this facility.

Findings include:

Staff failed to monitor patient care needs, adjust treatment plans/goals according to patient change in condition and evaluating patient response to interventions. See tag A396.

The impact of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility.

Based on record review and interview staff failed keep patient care plans updated when patients have a change of condition and implement and apply appropriate monitoring and interventions in 2 of 10 medical records reviewed. (Pt 1, 5). This could potentially impact all 24 patients receiving treatment at this facility.

Findings Include:

Review of policy and procedure titled, "Assessment/Reassessment of Patients.." effective 6/2014 states the following:

-The plan of care should identify the needs to be addressed, the care goal relative to the need identified, interventions planned to address the needs and meet the goal, and monitoring of the patient's progress towards achieving the care goal.


Review of Pt 5's medical record on 3/14/16 beginning at 2:40 PM, revealed Pt 5 was admitted on 11/13/15 at 1:45 PM to the behavioral health unit status post a suicide attempt. Pt 5 was placed on suicide precautions level 2 as part of Pt 5's plan of care.

Per policy titled, "Suicide Assessment, Management and Precautions" last reviewed 6/15, Level 2 suicide precautions require that, "the patient is checked every 15 minutes" and that "certain objects may be removed from the patients room to provide safety of the patient and others".

Review of Pt 5's "Precaution Record" showing documentation of Pt 5's 15 minute safety checks shows the following:

11/13/15-- No evidence of 15 minute checks at 2:45 PM, 3:00 PM, and 3:15 PM
11/14/15--No evidence of 15 minute checks at 5:45 am, 6:00 am, and 6:15 am
11/16/15--30 minute checks documented from 2:30 PM to 6:30 PM, despite order for 15 minute checks.
11/17/15--No evidence of 15 minute check at 6:00 am

Per interview with Administrative Director "A" on 3/14/16 beginning at 3:35 PM, staff should be documenting patient safety checks every 15 minutes on Pt 5's "Precautions Record" as evidence of staff performing patient safety checks.

Per facility occurrence report, on 11/17/15 documentation stated the following; "Writer found pt (Pt 5) sitting in shower, not responding to writer, pt's face was blue. Writer saw a white piece of cloth wrapped around pt's neck...writer was able to quickly unwrap cloth from pt's neck and undo two knots."

Per facility occurrence report, on 11/24/15 documentation stated the following; "...pt was found under the blanket with gauze wrapped around (Pt 5's) neck. pt's face was blue."

Per interview with Administrative Director "A" and Director of Risk Management "G" on 3/14/16 beginning at 10:30 AM, Pt 5 used a piece of a ripped towel to wrap around Pt 5's neck in both suicide attempts. "A" stated Pt 5 was still allowed unsupervised access to towels even after Pt 5 was found with a piece of towel wrapped around neck during the first suicide attempt on 11/17/15. No change or update was added to Pt 5's care plan addressing nursing interventions on Pt 5's towel usage and monitoring to prevent reoccurrence, and on 11/24/15 Pt 5 attempted suicide again using same method previously used 7 days earlier.

Review of Pt 5's "Interdisciplinary Plan Of Care" showed no evidence of staff reviewing and updating plan of care goals and documenting individualized interventions on the "Interdisciplinary Plan of Care" form after Pt 5 attempted suicide on 11/17/15 or 11/24/15.

Per interview with Administrative Director "A" on 3/14/16 beginning at 3:35 PM, staff should be updating the care plan when there is a change of condition.

Review of Pt 1's medical record 3/15/16 beginning at 11:10 am shows Pt 1 was admitted on 2/25/15 for Catatonic Schizophrenia and placed on 30 minute safety checks. Per Pt 1's "Precaution Record" on 2/25/16 Pt 1 was placed on 15 minute checks due to wandering in patient rooms. Pt 1's "Precaution Record" shows safety checks were not documented every 15 minutes as ordered:

2/27/16-- 30 minute checks documented from 12:30 am to 2:30 PM
3/1/16-- 30 minute checks documented from 12:30 am to 6:30 am
3/3/16-- 30 minute checks documented from 5:00 am to 7:30 PM
3/4/16--30 minute checks documented from 12:30 PM to 10:00 PM
3/5/16--30 minute checks documented from 5:30 am to 11:30 PM

Per interview on 3/14/16 beginning at 12:00 PM with Administrative Director "A", "A" was unable to provide evidence of the physician changing the level of monitoring back to 30 minute safety checks. Per "A" a nursing order can increase level of monitoring, but a physician order is required to decrease a patient's level of monitoring. "A" stated Pt 1 should have been performing safety checks every 15 minutes as evidence by documenting every 15 minutes in Pt 1's "Precaution Record".

Based on observation and interview staff failed to ensure a safe environment for behavioral health patients in 9 of 9 patient rooms observed (room 320, 321, 322, 317, 331, 211, 212, 208, 219) 1 of 1 shower room. This could potentially impact all 24 patients receiving treatment at this facility.


Findings include:

Staff failed to maintain a safe environment minimizing potential risk for suicide and self-injurious behaviors. See tag A701

The impact of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility. See tag.

Based on observation and interview staff failed to ensure a safe environment for behavioral health patients in 9 of 9 patient rooms observed (room 320, 321, 322, 317, 331, 211, 212, 208, 219) 1 of 1 shower room. This could potentially impact all 24 patients receiving treatment at this facility.


Findings Include:

Observations on 3/11/2016:

During tour of Behavioral Health facility beginning at 1:00 PM with Nurse Manager "B" and Clinical Therapist "C", observed 5 patient rooms on the adult floor (3 york), 3 patient rooms on the children/adolescent unit (2 york), and shower room. Observations of patient rooms revealed the following safety risks:

-Electrical outlets on walls (approximately 4 feet off the ground) in and outside of patient bathrooms are all covered with metal boxes; the metal boxes are secured with screws and protrude out from the wall approximately 1 inch. There is a 1/4 inch gap between the outlet plate and metal box, allowing for a ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk.

-Metal paper towel dispensers (attached to wall above sink) located in patient bathrooms contain sharp corners allowing potential for harm for patients with self injurious behaviors and/or suicide risk.

-Door handle housing unit (approximately 3 feet off the ground) on the inside and outside of patient's bathrooms protrudes approximately a 1 and 1/2 inches off the door at a 90 degree angle, allowing for a ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk.

-Call light in shower room protrudes approximately 2 and 1/2 inches off the wall and is secured in place with screws allowing for ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk. Per interview with Nurse Manager "B" at the time of the tour, "B" stated staff stand outside of shower room when patients are showering and patients are given towels to use inside the shower room.

Per observations on 3/15/16 beginning at 1:30 PM, Medical Doctor "Q" was able to rip the elastic out of a fitted sheet used on the behavioral health units and create a ligature. "Q" wrapped the ligature around the door handle housing unit and attached other end around "Q's" neck for the purpose of demonstration of ways patients could potentially attempt suicide. "Q" was able to apply enough pressure to neck to cut off oxygen supply without the ligature slipping off the door handle housing unit. Per interview with "Q" at the time of demonstration, "Q" stated, "I guess this would work." "Q" stated "Q" was not aware fitted sheets with elastic were still being used on the units. Director of Quality "R" and Director of Risk Management "G" (both present at the time of observation) and Medical Doctor "Q" were asked to attempt to rip a flat sheet and demonstrate the same situation. Staff found a flat sheet and identified a hole/defect in the flat sheet, "R" and "Q" were able to rip the flat sheet and create a ligature. "Q" wrapped the ripped piece of flat sheet around the door handle housing unit and attached other end to "Q's" neck and again was able to apply enough pressure to neck to cut off oxygen supply without the ligature slipping off the door handle housing unit.