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Based on interview, record review, and policy review the facility failed to:
- Protect one current patient (#7) from attempting to strangulate herself when she barricaded the doorway with the bed mattress then removed the elastic waistband from her paper scrubs and tied it around her neck while she was a patient in the Emergency Department (ED). (Refer to A-0144)
- Increase her level of observation/supervision when she was transferred from the ED to the Behavioral Health Unit (BHU) which allowed the patient to make a second attempt to strangulate herself when she again used the elastic waistband from her paper scrubs and tied it around her neck when she was in the shower that resulted in loss of consciousness. (Refer to A-0144).
- Follow facility policy for observation rounds for the inpatient BHU when one staff (P) failed to visually observe the patient when completing the 15 minute safety rounding while the patient was in the shower. (Refer to A-0144)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 74.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 06/20/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 06/20/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Revision to ED Suicide Risk Assessment and Intervention Guidelines Policy: 1) Require assignment to 1:1 within arm's reach observation of patients observed by a Registered Nurse (RN) with an increase in suicidal risk or attempt. 2) Require all patients on 1:1 within arm's reach to remain on such precautions upon transfer to next level of care and 3) Policy updated to remove video monitoring language and add removal of cords 12 inches and longer as possible in non-psych rooms in the ED used for suicidal patients.
- 100% of staff currently working and scheduled to work ED night shift on 06/20/18 on the BHU and ED received revised policy and sign in attestation confirming receipt and understanding of policy revisions. 100% of staff must review revised policy and sign attestation prior to patient care.
- 100% Suicidal patients audited to validate appropriate level of observation was put into place for a one week period, if 100% were appropriate within first week then an audit of 50% of the charts for the next two week period will occur. If 100% compliance reached audit will occur on 25% of patient on a monthly basis, if 100%, audits will be maintained at 25% per quarter.
- Revised BHU Suicide Assessment and Prevention Policy: 1) Requires patients coming to the BHU on 1:1 within arm reach observation to remain on precaution until assessed by psychiatric provider and deemed no longer at risk to self or others. 2) Patient who have made a suicide gesture or attempt prior to admission to be placed on 1:1 observation.
- 100% of currently working BHU staff and those scheduled to work evening shift of 06/20/18 on BHU will receive revised policy and sign an attestation confirming receipt and understanding of revisions to policy. 100% staff must review revised policy and sign attestation prior to work assignments.
- 100% suicidal patients audited to validate appropriate level of observation was placed for a one week period, if 100% were appropriate within the first week, audit of 50% of charts for the next two weeks will occur, if 100% compliance reached audit will occur on 25% of patients on a monthly basis, if 100% maintained then audits will be at 25% per quarter.
- Evaluate scrub options from suppliers for changes that can be implemented with exploring "psychiatric patient pajama" options. Current paper scrubs have been altered to cut the elastic waistband into four sections prior to patient use.

Based on interview, record review, and policy review, the facility failed to protect one patient (#7) from repeated self-harm, of one patient reviewed for self-harm, when she attempted to strangle herself in the Emergency Department (ED) and in the Behavioral Health Unit (BHU).
These failures had the potential to affect all patients who were at risk for self-harm in the facility. The facility census was 74. The BHU census was 15.

Findings included:

1. Review of the facility's policy titled, "Suicide Assessment and Prevention," dated 07/2014, showed that all patients were to be monitored at least every 15 minutes, and patients who were assigned to be at moderate or high risk for suicide may be placed on Level I-within line of sight observation or Level II-within arm's length observation.

2. Review of Patient #7's ED record showed:
- Patient #7 was brought to the ED on 06/11/18 at 2:52 AM, with an affidavit (written statement confirmed by oath or affirmation) for a court ordered psychiatric hold, after police talked her down from a building, after she threatened suicide.
- History and Physical (H&P) documentation that the patient was depressed with suicidal ideation (thoughts of ending one's life).
- An observation order dated 06/11/18 at 3:00 AM, which directed staff to monitor the patient for suicide precautions (precautions taken by staff to ensure the patient is safe) and elopement precaution (precautions taken by staff to ensure the patient does not leave), within line of sight at all times/every 15 minutes,
- Nurses notes dated 06/11/18 at 8:54 PM, which documented that the patient was monitored by video sitter (staff member assigned to observe one or more patients through live video monitoring).
- Nurses notes dated 06/11/18 at 9:09 PM, which documented that the patient was noted by the sitter to be chewing on her pants in her room.
- Nurses notes dated 06/11/18 at 9:11 PM, which documented that the patient's sitter notified the nurse, that the patient stood in the corner of the room, took the mattress off the bed, tried to barricade the door, ripped out elastic from her (hospital provided paper scrub) pants and attempted to strangle herself.
- Nurses notes dated 06/12/18 at 6:41 PM documented that the patient was transferred to the BHU at 1:20 PM.

During a telephone interview on 06/20/18 at 12:40 PM, Staff X, Comfort Care Companion, stated that she was responsible for video monitoring of the patient on 06/12/18 in the ED, and she observed the patient pull at her pants, remove the elastic and tie it around her neck.

During an interview on 06/20/18 at 9:18 AM, Staff W, Registered Nurse (RN), ED Manager, stated that an active attempt of suicide required a one on one observation (one staff member assigned to watch one patient at all times).

Review of the facility's policy titled, "Observation Levels," dated 07/2014, directed staff that the minimum level of observation for all patients was Level One, and to assess and document at 15 minute intervals. The attending physician was always contacted to provide the level of observation order.

During a telephone interview on 06/20/18 at 9:05 AM, Staff V, ED Physician, stated that he did not speak with Staff L, Psychiatrist, after Patient #7 attempted to self-harm in the ED, and when he wrote admission orders, they did not include observation levels because it was not the ED Physician's responsibility.

During an interview on 06/19/18 at 1:00 PM, Staff L, Psychiatrist, stated that it was the ED Physician's responsibility to order the level of observation for patients being admitted to the BHU, and that the level of observation for a patient on suicide precautions was every 15 minute checks.

Because an observation level was not ordered for Patient #7, the patient would be observed every 15 minutes. There was no increased level of observation upon her admission to the BHU after she attempted self-harm in the ED.

During an interview on 06/20/18 at 3:00 PM, Staff N, BHU RN, stated that he was aware the patient had attempted to self-harm while in the ED, but wasn't concerned with the patient's level of observation of every 15 minute checks, because of her demeanor and attitude on her arrival to the BHU.

3. Review of Patient #7's inpatient care plan notes showed the patient arrived on the BHU on 06/12/18 at 1:23 PM. The initial intake showed the patient was cooperative, denied current thoughts of suicide and contracted for safety. At 4:13 PM, the patient was found unresponsive, and was transported to the Intensive Care Unit (ICU).

During an interview on 06/19/18 at 2:00 PM, Staff N, BHU RN, stated that:
- He knocked on Patient #7's room door, received no response, opened the door and heard the shower running and noted that the bathroom door was closed. He called the patient by name and then asked Staff U, MHT (female), to visualize the patient.
- When Staff U opened the bathroom door, the patient was lying on the floor with something tight around her neck, her face was purple (sign of asphyxiation, lack of oxygen, possible sign of impending death) with petechiae, and her lips were turning blue. She was not responsive, and the right side of her neck and jaw were red.
- He cut a layer of what was tied around her neck and the patient started to "come around," opened her eyes, and was transported to the ICU.

During an interview on 06/19/18 at 4:15 PM, Staff T, ICU RN, stated that when he responded to Patient #7 on the BHU, the patient was not responsive to pain (unable to get a response when pain was delivered), did not respond to a chest rub and had petechiae around her neck and on her face

4. Review of the facility's policy titled, "Observation Rounds for Inpatient Behavioral Health Services," dated 06/2014, directed staff to observe a minimum of every 15 minutes, not to exceed 20 minutes, during their entire hospitalization, and to document the patient's location only after visual assessment had been completed, including if the patient was in the bathroom or showering.

During an interview on 06/19/18 at 2:48 PM, Staff P, MHT, stated that:
- She was responsible for doing rounds every 15 minutes for Patient #7 on the day of the event.
- She knocked on the patient's door during her rounds, but she did not visualize the patient because the patient was in the shower.
- The policy was to check and visualize patients every 15 minutes.

During an interview on 06/20/18 at 7:35 AM, Staff U, MHT, stated that during 15 minute rounding, patients should be visualized, every time.

Review of the rounding sheet for Patient #7 dated 06/12/18 showed at:
- 3:30 PM, the patient location was documented as being at the nurses station and the activity was talking with staff, initialed by Staff P, MHT.
- 3:45 PM, the patient location was documented as in the patient room with activity of daily living (ADL), initialed by Staff P, MHT.
- 4:00 PM, the patient location was documented as in the patient room with activity not documented and was not initialed by any staff.

Patient #7 was admitted to the BHU at 1:23 PM on 06/12/18 on every 15 minute rounding checks after she attempted to strangulate herself while in the ED. The patient was not visualized from 3:31 PM to 4:12 PM (41 minutes), and at 4:13 PM, the patient was found unresponsive after she attempted to strangulate herself again with the elastic waistband (confirmed by hospital administration) from her paper scrubs.











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