HospitalInspections.org

Based on interview, record review and policy review the hospital failed to:
- Ensure the safety of all patients when they failed to identify, investigate and educate all staff in response to the attempted suicide (to cause one's own death) of one discharged patient (#49) of two safety events reviewed.
- Provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for one patient (#43) of two medical records reviewed.
- Follow their internal policy for every 15-minute rounding for Behavioral Health Unit (BHU) patients for one current patient (#47) and 10 discharged patients (#39, #40, #41, #42, #43, #44, #45, #46, #48 and #49) of 11 medical records reviewed.
- Follow their internal policy for the frequency of completion for the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) in the BHU for one current patient (#47) and three discharged patients (#39, #42, and #49) of 10 medical records reviewed.

These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Based on interview, record review and policy review the hospital failed to:
- Ensure the safety of all patients when they failed to identify, investigate and educate all staff in response to the attempted suicide (to cause one's own death) of one discharged patient (#49) of two safety events reviewed.
- Provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for one patient (#43) of two medical records reviewed.
- Follow their internal policy for every 15-minute rounding for Behavioral Health Unit (BHU) patients for one current patient (#47) and 10 discharged patients (#39, #40, #41, #42, #43, #44, #45, #46, #48 and #49) of 11 medical records reviewed.
- Follow their internal policy for the frequency of completion for the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) in the BHU for one current patient (#47) and three discharged patients (#39, #42, and #49) of 10 medical records reviewed.

Review of the hospital's policy titled, "Suicide Risk Assessment and Reassessment for Behavioral Health Services, dated 12/2023 showed:
- In a behavioral health setting, we generally consider that there is some level of risk for virtually every patient and have an environment and a set of practices developed with this in mind. Psychiatric (relating to mental illness) units have a primary concern with patient safety with respect to potential for injury to self or others, differing in the respect from virtually all other acute care hospital units.
- For high, moderate and low risk suicide document observations every 15 minutes or more frequent as ordered.
- Rounds are required to be completed within three minutes to either side of each quarter hour.
- Reassess suicide risk with a reassessment tool every two hours for patients on 1:1 observation for suicide risk.
- Reassess suicide risk with a reassessment tool every four hours for patients assessed at high-risk but not on 1:1 observation.
- For moderate and low suicide risk reassess suicide risk with a reassessment tool at least daily.

Review of the hospital's policy titled, "Event Reporting," dated 11/08/23, showed:
- A patient safety event is an event, incident, or condition that resulted or could have resulted in harm to a patient.
- Suicide is a patient safety event.
- The department manager will conduct a brief/limited investigation on events which are precursor or near miss harm events. This information is critical for patient safety efforts and to prevent recurrence.
- For events with no harm, the department manager will complete an investigation within 14 calendar days of the reported date.
- The risk/quality department will review department supervisor/manager investigation and determine if additional investigation is needed within three business days of the reported date.
- The risk/quality department will establish a small core group to determine the safety event classification and whether the event meets the definition of a serious safety event.
- The risk/quality department will facilitate a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred to find the root cause) when an event meets the definition of a Serious Safety Event.
- The risk/quality department will complete the RCA within 45 days of event discovery.

Review of the hospital's document titled, "Event Report #1645410," dated 03/02/24 showed:
- During a 15-minute observation round, Patient #49 was found in the bathroom with a sheet around her neck.
- Patient #49 stated "I'm sorry."
- A written note showed "I'm sorry."
- The department manager did not investigate.
- A RCA was not completed.
- The event was not reported to the Department of Health and Senior Services (DHSS).

Review of Patient #49's medical record showed:
- On 03/02/24 she was a 19-year-old female admitted to the BHU for major depressive disorder (persistently low mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts).
- At 11:02 AM and 11:29 AM, every 15-minute rounds were completed, 27-minutes between rounds.
- At 12:17 PM and 12:40 PM, every 15-minute rounds were completed, 23-minutes between rounds.
- At approximately 12:30 PM, staff noticed on security camera that Patient #49 was in her bathroom, the sheets were off her bed and a piece of paper stuck out from under her door.
- The patient was found in the bathroom standing in front of the mirror.
- A sheet was draped over the back of her neck.
- She was starting to tie the ends of the sheet together.
- At 1:18 PM and 1:40 PM, every 15-minute rounds were completed, 22-minutes between rounds.
- At 2:30 PM, an order was written for 1:1 observation due to high-risk suicide.
- On 03/03/24 at 4:00 PM and 6:55 PM, the CSSR was completed, 55 minutes late.
- On 03/05/24 at 8:45 AM and 9:00 PM, the CSSR was completed, ten hours and 15 minutes late.
- On 03/06/24 at 12:00 PM and 10:00 PM, the CSSR was completed, eight hours late.
- At 10:00 PM and 03/07/24 at 8:45 AM, the CSSR was completed, eight hours and 45 minutes late.
- At 4:21 PM, the 1:1 observation order was discontinued.

Review of Patient #43's medical record showed:
- On 05/03/24, she was a 28-year-old female admitted to the BHU for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for walking erratically down a street with very erratic movements. She appeared intoxicated and had a history of drug use.
- At 10:30 PM, a provider order was written for 1:1 observation for patient safety related to fall risk.
- At 10:43 PM. Staff RR, PCT was assigned the 1:1 observation and rounded every 15 minutes on 14 other patients.
- On 05/04/24 at 7:03 AM through 6:45 PM, Staff LL, PCT provided 1:1 observation and rounded every 15 minutes on other patients.
- On 05/04/24 at 1:18 AM and 1:42 AM, every 15-minute rounds were completed, 24-minutes between rounds.
- At 3:47 AM and 4:07 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 4:24 AM and 4:44 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 7:38 PM, the 1:1 observation order was discontinued.

Review of Patient # 42's medical record showed:
- On 02/19/24 at 7:59 AM an order was written for 1:1 observation due to high-risk suicide.
- At 8:00 PM, the CSSR was completed, 11 hours late.
- On 02/20/24 at 7:00 AM, the CSSR was completed, nine hours late.
- At 10:23 PM, the CSSR was completed, 13 hours and 23 minutes late.
- On 02/22/24 at 9:30 AM, the CSSR was completed, nine hours and 7 minutes late.
- At 10:00 PM, the CSSR was completed, 11 hours and 30 minutes late.
- On 02/23/24 at 10:00 AM, the CSSR was completed, eight hours late.
- At 7:01 PM and 7:28 PM, every 15-minute rounds were completed, 27-minutes between rounds.
- At 7:47 PM and 8:08 PM, every 15-minute rounds were completed, 21-minutes between rounds.
- At 8:39 PM, she was transferred to the Emergency Department (ED) following a fall. Every 15-minute rounds were not performed in the ED between 10:22 PM and 11:28 PM.
- At 11:28 PM, she was transferred to the BHU.
- On 02/24 at 9:00 AM, the CSSR was completed, nine hours late.
- At 8:00 PM, the CSSR was completed, 9 hours late.
- On 02/25/24 at 8:00 AM, the CSSR was completed, ten hours late.
- At 8:02 AM and 8:29 AM, every 15-minute rounds were completed, 27-minutes between rounds.
- At 8:46 AM and 9:14 AM, every 15-minute rounds were completed, 28-minutes between rounds.
- At 10:33 AM and 10:57 AM, every 15-minute rounds were completed, 24-minutes between rounds.
- At 11:06 AM she was transferred to the ED after stuffing paper in her right ear.
- At 1:41 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED.
- At 3:35 PM, she was transferred to the ED again for stuffing paper in her right ear.
- At 4:09 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED.
- On 02/26/24 at 9:00 AM, the CSSR was completed, 11 hours late.
- At 12:49 PM and 1:14 PM, every 15-minute rounds were completed, 25-minute between rounds.
- At 1:19 PM and 1:42 PM, every 15-minute rounds were completed, 23-minutes between rounds.
- At 2:24 PM and 2:43 PM, every 15-minute rounds were completed, 19-minutes between rounds.
- On 02/26/24 at 3:05 PM, she was transferred to the ED after stuffing foam from a drinking cup and paper up her nose and in both ears.
- At 6:53 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED.
- At 8:00 PM, the CSSR was completed, nine hours late.
- On 02/27/24 at 8:00 AM, the CSSR was completed, ten hours late.
- At 8:13 PM, the 1:1 observation order was discontinued.

Review of Patient # 39's medical record showed:
- On 03/05/21 at 3:01 PM and 3:21 PM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 5:02 PM and 5:26 PM, every 15-minute rounds were completed, 24-minutes between rounds.
- At 6:22 PM and 6:42 PM, every 15-minute rounds were completed, 20-minute between rounds.
- At 7:01 PM an order was written for 1:1 observation due to high-risk suicide.
- On 03/09/24 at 2:00 PM and 8:00 PM, the CSSR was completed four hours late.
- On 03/10/24 at 8:00 PM and 03/11/24 at 12:00 AM, the CSSR was completed two hours late.
- At 4:00 AM and 9:00 AM, the CSSR was completed three hours late.
- On 03/11/24 at 11:00 AM and 4:00 PM, the CSSR was completed, three hours late.
- At 5:34 PM, the 1:1 observation order was discontinued.

Review of Patient # 47's medical record showed:
- On 05/13/24 at 5:35 PM and 7:10 PM, every 15-minute rounds were completed, one hour and 35-minutes between rounds.
- At 8:02 PM and 8:22 PM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 9:02 PM and 9:23 PM, every 15-minute rounds were completed, 21-minutes between rounds.
- On 05/16/24, no CSSR was completed.

Review of Patient # 40's medical record showed:
- On 04/12/24 at 7:16 PM and 7:44 PM, every 15-minute rounds were completed, 28-minutes between rounds.
- At 8:16 PM and 8:42 PM, every 15-minute rounds were completed, 26-minutes between rounds.
- At 8:49 PM and 9:09 PM, every 15-minute rounds were completed, 20-minutes between rounds.

Review of Patient # 41's medical record showed:
- On 02/26/24 at 9:20 AM and 9:40 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 10:01 and 10:26 AM, every 15-minute rounds were completed, 25-minutes between rounds.
- At 11:23 AM and 11:44 AM, every 15-minute rounds were completed, 21-minutes between rounds.

Review of Patient # 44's medical record showed:
- On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:37 PM Staff RR, PCT, provided every 15-minute rounds for Patient #44 while she was also assigned the 1:1 observation of Patient #43.
- On 05/03/24 and 05/04/24, Staff RR and Staff LL, PCT, provided every-15-minute observations for Patient #44 while also providing 1:1 observation for Patient #43.
- On 05/04/24 at 1:19 AM and 1:42 AM, every 15-minute rounds were completed, 23-minutes between rounds.
- At 3:47 AM and 4:07 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 4:24 AM and 4:44 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 7:05 AM through 6:48 PM, Staff LL provided every 15-minute rounds for Patient #44 while she was also assigned the 1:1 observation of Patient #43.

Review of Patient # 45's medical record showed:
- On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:36 PM Staff RR, PCT, provided every 15-minute rounds for Patient #45 while she was also assigned the 1:1 observation of Patient #43.
- On 05/04/24 at 7:04 AM through 6:47 PM, Staff LL, PCT, provided every 15-minute rounds for Patient #45 while she was also assigned the 1:1 observation of Patient #43.
- On 05/03/24 and 05/04/24, Staff RR and Staff LL provided every-15-minute observations for Patient #45 while also providing 1:1 observation for Patient #43.
- At 3:31 PM and 3:59 PM, every 15-minute rounds were completed, 28-minutes between rounds.
- At 4:31 PM and 4:59 PM, every 15-minute rounds were completed, 28-minutes between rounds.
- At 6:15 PM and 6:44 PM, every 15-minute rounds were completed, 29-minutes between rounds.

Review of Patient # 46's medical record showed:
- On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:36 PM Staff RR, PCT, provided every 15-minute rounds for Patient #46 while she was also assigned the 1:1 observation of Patient #43.
- On 05/04/24 at 7:04 AM through 6:47 PM, Staff LL, PCT, provided every 15-minute rounds for Patient #46 while she was also assigned the 1:1 observation of Patient #43.
- On 05/03/24 and 05/04/24, Staff RR and Staff LL provided every-15-minute observations for Patient #46 while also providing 1:1 observation for Patient #43.
- On 05/07/24 at 2:50 AM and 3:14 AM, every 15-minute rounds were completed, 24-minutes between rounds.
- At 4:09 AM and 4:29 AM, every 15-minute rounds were completed, 20-minutes between rounds.
- At 5:32 AM and 5:52 AM, every 15-minute rounds were completed, 20-minutes between rounds.

Review of Patient # 48's medical record showed:
- On 04/18/24 at 3:33 PM and 3:59 PM, every 15-minute rounds were completed, a 26-minutes between rounds.
- At 4:50 PM and 5:14 PM, every 15-minute rounds were completed, 24-minutes between rounds.
- At 6:18 PM and 6:40 PM, every 15-minute rounds were completed, 22-minutes between rounds.

During a telephone interview on 05/21/24 at 11:30 AM and 05/22/24 at 12:00 PM, Staff C, CNO, stated that she was not aware of Patient #49's suicidal gesture. She expected to be informed of all nursing and patient events. Any attempt of suicide needed to be taken seriously. She expected a RCA and staff education after "this type of event." She expected any gesture of a suicide attempt was reported to the DHSS. She stated that she was not aware a PCT simultaneously provided 1:1 observation and performed every 15-minute rounds on other patients. A staff member with a 1:1 assignment was not to be assigned other duties. Gaps in every 15-minute rounds did not meet her expectation. Every 15-minute rounds should never be missed for a patient on a 1:1 observation status. The hospital needed to strengthen leadership rounding to achieve a consistent practice. Staff C stated that she expected staff to follow all hospital policies.

During a telephone interview on 05/16/24 at 4:05 PM, 05/21/24 at 9:30 AM and 05/22/24 at 12:50 PM, Staff UU, BHU Director, stated that he considered a suicidal gesture to be a significant safety event. At the time of the event, he did not consider the significance of the "I'm sorry" note. Staff were complacent. It was unacceptable for staff to "let their guard down." He did not follow up with the staff involved in Patient #49's event or provide staff education. He stated that the simultaneous assignment of a 1:1 observation and every 15 rounding "should have never happened, patients were placed at risk." He would not have asked his team "to do the impossible." He did not perform any follow up investigation into the double assignment event. Staff UU stated that he expected every 15-minute rounds to be completed within the policy expectation of every 15-minutes with an allowance of a three-minute window. There were to be no gaps when a patient was on a 1:1 observation. There was an auditing process for every 15-minute rounds and he believed the rounding was "always done."

During a telephone interview on 05/16/24 at 4:00 PM, 05/21/24 at 8:30 AM and 05/22/24 at 12:15 PM, Staff MM, BHU Manager, stated that "sometime in early March a female patient made a gesture of suicide." Staff MM reviewed Patient #49's medical record for the care given after the suicide gesture. She did not investigate factors that led to Patient #49's suicidal gesture. She did not investigate as required per the Event Reporting Policy. She stated that on the morning of 05/04/24 she was notified the fall precautions were discontinued for Patient #43 and staffing was adequate. At 7:30 AM, she received a text message from the PCT asking about her simultaneous assignment of the 1:1 and every 15-minute rounds for other patients. She told the PCT to speak with the charge nurse, she was not supposed to provide 1:1 observation and also provide every 15-minute observation of other patients. Her expectation was 1:1 observation and every 15-minute rounding were not performed by the same staff member. She was not aware the PCT who worked the night of 05/03/24 provided the 1:1 observation for Patient #43 and every 15-minute rounds for other patients. Staff MM did not speak with the charge nurse. She did not perform any follow up investigation into the double assignment event. Staff BB stated that she expected "no gaps" in every 15-minute rounding. There was no excuse for gaps when a patient was ordered a 1:1 observation. Staff MM expected the CSSR's to be completed per the hospital policy. "A lot of education was provided about the CSSR completion expectations."

During a telephone interview on 05/22/24 at 10:45 AM, Staff BBB, Registered Nurse (RN), stated that he felt Patient #49's action was a "gesture for attention." That was an "expected event" in the BHU. Leadership did not debrief the event with him.

During a telephone interview on 05/22/24 at 1:35 PM, Staff DDD, RN, stated that she overheard the PCT for Patient #49 call out and she went to help. She felt the event was a significant safety event. Any type of event whether a patient was seeking attention or attempted suicide was to be taken seriously. Leadership did not debrief the event for Patient #49 with her.

During a telephone interview on 05/23/24 at 10:00 AM, Staff XX, PCT, stated that during her 15-minute observation rounds she found patient #43 in the bathroom, she knocked on the door, said she needed to enter and found the patient with the sheet "draped around her neck." Leadership did not debrief the event with her.

During a telephone interview on 05/22/24 at 11:30 AM, Staff CCC, BHU Intake Manager, stated that she was unaware the PCT was assigned the 1:1 observation for Patient #43 while also providing every 15-minute rounding for other patients. Staff ZZ, Charge Nurse, called Staff CCC and was told to pull the intake coordinator to cover the 1:1 observation of Patient #43 and discontinue the 1:1 observation order as soon as possible. She was unaware the licensed staff refused to be pulled to provide 1:1 observation. "This should never happen." One to one observation and every 15-minute observations simultaneously were "impossible" for one staff member. No leadership follow up was performed in response to this double assignment event.

During a telephone interview on 05/22/24 at 10:35 AM, Staff AAA, House Supervisor, stated that he did not recall Patient #43. He expected the charge nurses to escalate staffing issues to their departmental leadership when he was unable to pull staff to cover short shifts. Failure to provide 1:1 observation for Patient #43 did not meet his expectations.

During a telephone interview on 05/22/24 at 10:25 AM, Staff ZZ, Charge Nurse, stated that when patient #43 was awake, she was "very high acuity." She was a "all hands-on deck patient, a two to three staff members to one patient acuity." She called the House Supervisor and was told there were no staff available to provide 1:1 observation for Patient #43. She called Staff CCC, BHU Intake Manager, but did not ask her to come into the hospital and help. The PCT sat outside of Patient #43's doorway when she was not providing every15-minute rounds for the other patients. Staff ZZ had 11 patients herself. Patient #43 went to sleep around 5:00 AM. When Staff ZZ returned to work that evening, Patient #43 remained on 1:1 observation.

During a telephone interview on 05/21/24 at 11:00 AM, Staff KK, Charge Nurse, stated that her understanding was the 1:1 order was "no longer in effect" for Patient #43. She told the PCT to watch Patient #43 for falls.

During a telephone interview on 05/16/24 at 10:35 AM, Staff LL, PCT, stated that on 05/04/24 she was assigned the 1:1 observation of Patient #43 and also every 15-minute observations of 14 other patients. She spoke with Staff KK, Charge Nurse, and was told "it's just until an assessment of Patient #43 was performed." The 1:1 assignment remained in place "all day." She called Staff MM, BHU Manager, and was told to talk to the charge nurse, and "to not call her on her day off." Staff KK, told her to "watch the patient better."

During a telephone interview on 05/21/24 at 10:30 PM, Staff RR, PCT, stated that she reported to the charge nurse, simultaneous 1:1 observation and every 15-minute rounds on other patients was "unethical." She stated that there was "plenty of staff" to cover the 1:1, but it required a licensed staff member to be pulled to the PCT role. She stated that "I had to do what the licensed staff said." She spoke with other nurses and was told "we have to do what we have to do." She was told the 1:1 observation was to be discontinued during the day. When she returned to work that night, the patient was still ordered 1:1 observation. Staff MM, BHU Manager, was aware and responded, "there was enough staff." The House Supervisor stated that there were no sitters available at the hospital and the BHU staff had to "figure it out themselves." She did not speak with Staff MM, because "she stands by her nurses." She did not report the event to Staff UU, BHU Director, he would have said "you knew better."