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Based on record review, interview, and observation, the hospital failed to protect and promote the right of 31 out of 31 suicidal patients (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41) to receive care in a safe setting.


1) Although identified as a safety risk prior to survey, metal framed beds with multiple spaced bars potentially usable for ligature during a suicide attempt were assigned to all suicidal patients.

2) Staff observational rounds were not completed for all patients.


Refer to A 144

Based on record review, interview, and observation, the hospital failed to ensure the right of 31 out of 31 patients on suicide precautions (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41) to receive care in a safe setting.


1) Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41 were identified by hospital staff as on suicide precautions during the survey. The patients were assigned beds with metal frames that provided multiple ligature points.


2) Patient #24 was noted impaired, in need of close monitoring, and on suicide precautions. The patient was assigned a metal bed and had the opportunity for a suicide attempt during 43 minutes of no staff observation.


Findings included:


During an interview on 05/12/17 at 1314 Personnel #7 identified 17 patients (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #24) to be on suicide precautions.


Observations on the hospital's two-winged patient care unit on 05/12/17 between 0950 and 1245 reflected Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #24 were assigned metal beds with spaced bars for multiple ligature points.


During an interview on 05/26/17 at approximately 1030, Personnel #1 provided the surveyor with a list that identified 14 patients (Patients #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #24) to be on 15-minute staff observation checks for suicide.


Personnel #8 stated on 05/26/17 at 1310 that Patient #41 was suicidal.


Observations on the hospital's patient care unit on 05/26/17 between 1310 and 1320 reflected Patients #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #24, and #41) were assigned metal beds with ligature risks.


Personnel #3 was interviewed on 05/12/17 at 1330. Personnel #3 stated metal beds had been identified as a ligature risk during a hospital safety meeting on 05/03/17 and would be replaced in "six to eight weeks."


Record review of Hospital Policy titled "Suicide Assessment and Prevention" dated 02/01/17 reflected the policy to "...provide a safe and supportive clinical setting..."



2) Record review of Patient #24's Complete Nurse Practitioner Evaluation dated 05/09/17 at 1411 reflected the patient had attempted suicide and needed inpatient care.


Patient #24's Physician Progress Note dated 05/12/17 at 1216 reflected the patient was "severely functioning impaired" and needed "careful supervision and monitoring."


Record review of Patient #24's staff 15-minute observation form dated 05/23/17 reflected no staff observation documentation between 1246 and 1329.


Personnel #9 acknowledged the finding during an interview on 05/26/17 at 1315.