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Based on interview, medical record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure the safety of one (1) patient (Patient #1), in the selected sample of ten (10) patients, due to failure to adhere to the policies and procedures pertaining to routine searches of personal belongings after admission, and as the policies pertain to every fifteen (Q 15) minute observations.

The Findings include:

Patient #1 received a pair of shorts post-admission which was not properly searched. An elasticized string was encased in the waistband and there was a slit in the waistband to allow the elasticized string to be pulled to tighten the garment. Additionally, he/she was placed on special care, and the patient was required to remain in his/her room during free time following an outburst in the cafeteria. Registered Nurse (RN) #6 removed Mental Health Technician (MHT) #2 from direct patient care to complete another task, leaving MHT #9 to cover all of the patients in the unit. Due to the activity on the unit, MHT #9 missed the Q 15 minute check on 04/27/14 at 7:00 PM. As a result of the aforementioned failures, MHT #9 went to check on Patient #1 at approximately 7:11 PM, and found the patient lying on the bathroom floor with the elasticized string from his/her shorts wrapped around his/her throat, crossed in the front and pulled up over his/her head.

These failures placed patients at risk for injury, harm, impairment, or death. Immediate Jeopardy was identified and determined to exist related to Patient Rights; however, the facility initiated corrective actions prior to the initiation of the survey and removed the Immediate Jeopardy prior to the survey exit on 05/12/14.
Refer to A-144

Based on interview, medical record review, review of staff statements taken by the facility's Risk Manager, and review of the facility's policies and procedures, it was determined the facility failed to ensure the safety of one (1) patient (Patient #1), in the selected sample of ten (10) patients, due to the failure to adhere to the policies and procedures entitled "Safe Environment", related to routine searches of personal belongings after visitation and Levels of Observations/Special Precautions as it pertains to every fifteen (Q 15) minute checks. Patient #1 was admitted to the facility on 04/17/14 at 5:49 AM. Patient #1 was admitted after threatening suicide and putting a gun to his/her head. On 04/27/14 at approximately 5:00 PM, Patient #1 was placed on special care for a minimum of sixteen (16) waking hours due to physical aggression toward a peer. During shift change at 7:00 PM, Mental Health Technician (MHT) #2 was allegedly removed from direct patient care by Registered Nurse (RN) #6, leaving MHT #9 with the responsibility of eighteen (18) patients on the unit. MHT #9 missed the 7:00 PM Q 15 minute check on Patient #1 due to other activity on the unit. MHT #9 checked on Patient #1, at approximately 7:11 PM, and found him/her lying on the bathroom floor with the elasticized string from his/her shorts wrapped around his/her throat, crossed in the front and pulled up over his/her head.

The Findings include:

Review of the facility's policies and procedures regarding "Safe Environment", revealed the policy required searches to be conducted on all patients and their belongings upon admission, as new personal belongings were brought in, and after visitation. Additionally, the policy stated "search after visitation/pass: items brought in by visitors for patient use will be searched prior to the patient's possession of these items."

Review of the facility's policy, "Levels of Observation/Special Precautions", revealed the policy required staff to conduct routine 15 minute checks (Q 15) on all patients. The policy stated, "Staff will make direct visual contact with the patient and document on the Patient Observation Round Sheet every 15 minutes. Hand off assigned "Patient Observation Sheets" to another staff member before leaving the patient treatment area (meals, breaks, emergencies)."

Review of the facility's policy, "Patient Belongings Inventory", revealed personal belongings were searched at the time of admission to ensure no contraband got to the unit. Additionally, the policy stated, when personal items for a patient were received from a visitor, the item(s) were identified with the patient's first name and last initial, and upon initial observation, any noted contraband will be returned to the visitor for removal from the facility.

A review of the facility's security video, dated 04/27/14 beginning at 6:25 PM, revealed the 7:00 PM Q 15 minute check was missed for Patient #1. MHT #9 entered Patient #1's room at 6:39 PM and exited at 6:41 PM. There was no evidence of activity observed on the video in Patient #1's room until 7:10 PM when MHT #1 checked on the patient. Between 7:12 PM and 7:35 PM, several staff entered and exited Patient #1's room. At 7:44 PM, Patient #1 was observed exiting his/her room with RN #11.

Review of staff statements provided to the facility's Risk Manager, revealed MHT #9 reported he had not completed the 7:00 PM Q 15 minute check on Patient #1. He was behind on the checks due to other activity on the unit, and he had all the other patients taken care of. The nurses were behind the desk during this time and would not take the book. MHT #9 reported he went to check on Patient #1 and found the patient lying on the floor in the bathroom and observed a string around his/her neck, which was crossed in the front of his/her throat and brought up over his/her head. A Code Blue was called, and he removed the string which was around the patient's throat, and other staff came to assist with the patient. MHT #9 also reported when he found Patient #1, he/she had a pulse but he did not notice any rise and fall of the patient's chest.

MHT #2 reported she gave her book (patient book) to MHT #9 because she was pulled from direct patient care by RN #6 to call the Department of Community Based Services (DCBS) regarding an allegation made by another patient. She stated there was no formal "hand off" of her patients. Additionally, she stated Patient #1 was on special care in his/her room. When she heard the Code Blue called, she responded and found Patient #1 with the string wrapped around his/her neck. Patient #1 had a strong pulse but appeared to not be breathing. Other staff arrived to assist and Patient #1 was revived. She took her book back from MHT #9 and noticed there were two (2) blanks on the Q 15 minute check sheet.

Patient #1 reported he/she was placed on special care, and was alone in his/her room which gave him/her time to think. Patient #1 reported he/she had not been checked on for ten (10) minutes and he/she used this time to attempt suicide. He/she removed his/her shorts and was folding them when he/she noticed the string, then took the string from the shorts, and wrapped it tightly around his/her neck and head while standing in front of the mirror, and recalled waking up on the floor. Additionally, Patient #1 stated he/she was not suicidal prior to the fight in the cafeteria. Patient #1 reported he/she believed the pair of shorts with the string was brought in to the facility on 04/26/14.

RN #4 reported she responded to the code. After the patient was stabilized, she contacted Patient #1's mother to explain what happened. Additionally, she reported she noticed the Q 15 minute sheet had blanks from 7:00 PM through 7:45 PM, so she initialed them as being done. She believed she had been with the patient during that time frame when she responded to the Code Blue.

Review of Patient #1's medical record revealed he/she was admitted to the facility on 04/17/14 due to threatening suicide while putting a gun to his/her head. At the time of admission, the patient was on Level II observations with suicide precautions. Review of nurse's notes revealed, on 04/27/14 at approximately 5:00 PM, Patient #1 physically attacked a peer in the cafeteria and was placed on special care for sixteen (16) waking hours. Review of the 7:19 PM nurse's note revealed, "the patient was found by the MHT with a string from his/her gym shorts tied around his/her neck, unresponsive, in the bathroom. The MHT called a Code Blue and untied the string from his/her neck. Patient#1 was breathing and had a strong pulse. Staff arrived and placed an ammonia capsule under his/her nose and the patient started to wake up. The patient's vital signs were taken. Initial vital signs were Blood Pressure (BP) 163/80 mm/hg, Pulse 83, Respirations (R) 20, and O2 Saturation 99 percent (%). The physician was notified and all required management was notified. Review of the nurse's notes, revealed, at 7:30 PM, "rechecked vitals. BP 118/55 mm/hg, Pulse 92, R 16, O2 99%". Patient #1 stated, "I had plenty of time to think about everything since I was alone in my room on special care. I have been upset and stressed about all the pain I have caused my family. The string I used was hidden in my gym shorts that could not be seen because it was sewn in the fabric." Patient #1 was placed on one (1) to one (1) care and remained with staff at all times. Continued to monitor the patient and maintain safety. Review of the Q 15 minute sheet revealed all fifteen (15) minute checks were documented as completed by RN #4, one of the RNs who responded to the Code Blue.

Interview with MHT #1, on 04/30/14 at approximately 2:55 PM, revealed she accepted three (3) pairs of shorts for Patient #1 on Saturday, 04/26/14 at approximately 3:30 PM. She conducted the search of the clothing and found strings in two (2) of the three (3) pairs of shorts, got permission to cut the strings out, actually cut the strings out, logged the clothing on Patient #1's "Personal Belongings Inventory Sheet", and gave the clothing back to Patient #1.

Interview with MHT #2, on 05/05/14 at approximately 10:40 AM, revealed she handed her book of patients off to MHT #9 after being removed from direct patient care by RN #6, leaving MHT #9 responsible for all eighteen (18) patients on the unit. She stated she responded to a Code Blue. She observed Patient #1 lying on the bathroom floor with a string pulled around his/her neck and the string was crossed in the front. She reported Patient #1 had a pulse but was not breathing at first. She stated she touched his/her rib area, and a nurse was doing a sternum rub on his/her chest. Then a nurse had an ammonia pack and waved it under the patient's nose and he/she started waking up.

Interview with RN #6, on 05/07/14 at approximately 12:38 PM, revealed she had clocked out, heard the Code Blue and returned to the unit to help. She put a blood pressure cuff and pulse oximeter on Patient #1 and told them to call the physician. She stated there were two (2) other nurses present. The patient started talking to the MHT, and the physician was notified. She told the nurses she had already clocked out and was leaving. Additionally, she reported she did not pull MHT #2 from direct patient care. She told her she would have to call DCBS before she went home and gave her the number to DCBS. MHT #2 asked MHT #9 to take her book and he said yes, and that was when she left the unit, and MHT #2 should have been back on the floor. RN #6 also stated she was unaware of any of the Q 15 minute checks being missed.

Interview with RN #4, on 05/07/14 at approximately 7:22 AM, revealed she was on the adult unit at the time of the incident. A Code Blue was called on the adolescent unit and she responded to the code. She stated, by the time she arrived, the shorts/string had been removed from around Patient #1's neck. Patient #1 was breathing, had a natural color, and a pulse. She reported his/her vitals were taken at at 7:15 PM, and she recalled this information because she looked at her watch, and wrote the time and the vital signs on her hand. She reported asking Patient #1 if he/she could hear her, and the patient responded yes. The patient was put on one (1) to one (1) observation. She stated she remained with Patient #1 until 7:45 PM. She reviewed the patient's chart, noticed the blanks on the Q 15 minute sheet from 7:00 PM to 7:45 PM, so she initialed the blanks because she was with the patient during that time while responding to the Code Blue.

Interview with the Risk Manager, on 04/30/14 at approximately 12:15 PM, and on 05/06/14 at approximately 9:35 AM, revealed while she reviewed the security video, dated 04/27/14, she noticed no staff had completed the 7:00 PM Q 15 minute check for Patient #1. She also reported MHT #9 told her he asked for help from the nurses. MHT #2 was pulled from direct patient care and he was involved with other patient activity which caused him to miss the 7:00 PM Q 15 minute check on Patient #1.

Interview with the Director of Clinical Services, on 05/06/14 at approximately 9:51 AM, revealed there was not a policy which defined special care. According to the Director of Clinical Services, the form used when a patient was put on special care best described what special care was, and the length of time the patient would be on special care. She also stated Patient #1 should have been better supervised.

Interview with RN #3, on 05/06/14 at approximately 2:34 PM, revealed she was on the 6:30 PM to 7:00 AM shift on 04/27/14. She reported the nurses were giving report and counting medications at shift change, and MHT #2 was on the phone, leaving MHT #9 to care for eighteen (18) patients. There was a lot of patient activity on the unit, and MHT #9 tried to watch the patients in the group room with all of the activity and missed the Q 15 minute check. She also stated a nurse could have assisted with the Q 15 minute checks.

MHT #9 was unavailable for interview due to a family emergency.

Review of re-training documentation, revealed all staff were re-trained on how to conduct searches of personal belongings, patient belongings inventory, patient hand off, and levels of supervision, beginning on 04/28/14. All staff were trained by 05/01/14.

Review of an e-mail sent from the Nurse Manager (RN #7), revealed the facility discontinued the practice of special care completely, effective 05/07/14, as any part of treatment for adolescent/child patients.

Review of the Patient Belongings Inventory policy with a revision, dated May 2014, revealed all searches of personal belongings will be conducted in the quiet room/seclusion room, which was a secured area.

Interview with the Director of Nursing (DON), on 05/07/14 at approximately 12:19 PM, revealed he conducted re-trainings with the entire nursing staff which included all nurses, MHTs, the Scheduling Coordinator, and the ward clerk. The re-training included information about patient belongings, searches, inventory sheets, levels of observation, documentation basics, patient hand off, and imminent risk. Additionally, he reported nurses were to be out in the milieu assisting the MHTs with direct patient care.

Interview with the Chief Executive Officer (CEO) and the Risk Manager, on 05/07/14 at approximately 2:17 PM, revealed the policy on Patient Belongings Inventory was revised to state all searches will be conducted in a secured area.

Interview with the Director of Clinical Services, on 05/06/14 at approximately 2:22 PM, and on 05/07/14 at approximately 9:48 AM, revealed she reported the new Incentive Points program will focus on reinforcing positive behavior and will replace the current behavior modification program. The patient will not be in his/her room due to behavior issues. She reported the official end date of using special care was 05/07/14. This was discussed in the treatment team meeting which was attended by all physicians, therapists, nurse managers, the DON, and the assigned nurses. This information was posted on the units on the communications binder which required all nurses to read at the beginning of their shift and provide a signature whenever they read it.

Interview with MHT #4, on 05/07/14 at approximately 3:00 PM, revealed she was re-trained to thoroughly complete searches of personal belongings, contraband, to double check clothing, that searches were only done in the quiet room/seclusion room, the levels of observation, to review any precaution levels of the patients, and ensure the whereabouts of the patients at all times. She stated as soon as we get our assignment sheet, staff get their eyes on the patients, and Q 15 minute checks must be completed timely. If staff get pulled off direct care, we must hand off our book to ensure the Q 15 minute checks were done.

Interview with RN #7, on 05/07/14 at approximately 3:05 PM, revealed she had been off work and would be re-trained prior to beginning her shift. She stated the re-trainings were regarding search techniques, documentation, hand off communications, and Q 15 minute checks. She stated she never stayed behind the desk and the other nurses on her shift were also out with the patients in the milieu. She stated, "When I am on the unit, nurses were not behind the desk." Additionally, she reported the facility no longer used special care and they used the incentive program to reinforce positive behavior.

Interview with MHT #5, on 05/07/14 at approximately 3:09 PM, revealed she was re-trained on searches at the point of admission. When additional personal belongings were brought in for a patient, searches were completed in the quiet room/seclusion room only. MHT #5 stated staff should look for contraband to include strings, wires, or anything a patient could use to harm himself/herself or others, and remove the contraband. Additionally, she reported the nurses were helpful if asked or when something was happening.

Interview with MHT #6, on 05/07/14 at approximately 3:14 PM, revealed she was re-trained on searches to look for anything that could be used by a patient to harm themselves or others, such as strings, pills, or contraband. Searches could only be conducted in a secure area, the seclusion room. Document clearly, Q 15 minute checks, levels of observation, as well as the staff must lay eyes on the patient.

Interview with the Unit Clerk, on 05/07/14 at approximately 3:28 PM, revealed she had to conduct searches to go through belongings, and look for anything that might be harmful, such as strings, pills, wires, or contraband. She reported she was not currently responsible for any direct patient care; however, she completed the Q 15 minute checks on the patients prior to admission. The patient remained in a locked room with the family or person who brought them to the facility. There were no cell phones, keys, or purses allowed in this room. Those items were kept at the front desk.

Interview with MHT #7, on 05/07/14 at 3:33 PM, revealed he was re-trained on search techniques, contraband, and that searches must be conducted in the seclusion room. When belongings were brought to the facility, searches were completed before the patient had access to them. Regarding levels of observation and Q 15 minute checks on time, he stated he would have to hand off his book if he left the unit. RNs were helpful on the unit and volunteered their assistance, not just when they were asked.

Interview with RN # 8, on 05/07/14 at approximately 3:45 PM, revealed he was re-trained on documentation, searches for contraband, personal belongings, and involvement with the MHTs regarding patient care. Additionally, he reported there was no longer a special care program, the incentive program took its place.

Interview with LPN #1, on 05/07/14 at approximately 3:51 PM, revealed she was re-trained on how to conduct searches, what to look for, Q 15 minute checks must be signed, whenever we hand off the book, we must sign it was handed off, and the person who accepted it signed as acceptance of the responsibility. We report any behavior changes, such as "no special care that ended today, and I help MHTs whenever possible with anything they need."

Interview with RN #5, on 05/07/14 at approximately 4:04 PM, revealed she was re-trained on searches. Personal belongings must be searched for contraband, strings, wires, and metal. The searches were conducted in the seclusion room,and items brought in after admission were also searched in the seclusion room. RN #5 stated, "I search clothing from the donations closet prior to issuing something to a patient." Every 15 minute checks were conducted by whomever was responsible for the patient, usually the MHT, but sometimes the nurses. Additionally, she assisted the MHTs voluntarily or when asked, and the facility no longer used special care.

Interview with the CEO, on 05/08/14 at approximately 10:30 AM, revealed his report revealed the donations closet items were completely searched, and no contraband was found.

Interview with the Risk Manager, on 05/08/14 at approximately 1:15 PM, revealed RN #11 called her, and stated he was with Patient #1 during the code until the patient was responsive.

Interview with RN #10, on 05/09/14 at approximately 12:03 PM, revealed she was re-trained on searches, personal belongings, inventory at admissions, and to search the seams of clothing. Searches were always conducted in the seclusion room. She stated staff search personal belongings when they were brought in for a patient, and were searched in the seclusion room. She stated we were out with the patients assisting the MHTs, doing Q 15 minute checks. She stated, "I do Q 15 minute checks depending on the need. When the MHT was busy, patient safety was first." Additionally, she reported special care was no longer used.

Interview with MHT #8, on 05/10/14 at approximately 11:21 AM, revealed she was re-trained on searches and the searches were always conducted in the seclusion room. Additional clothing post-patient admission was searched in the seclusion room also. The items would be placed on a patient personal belongings inventory list,and if anything seemed questionable, staff would not allow the patient to have it until approved by the nurse or the physician. The staff no longer implement special care, and now use the incentive program, which includes Q 15 minute checks, and a visual check on all patients. MHT #8 stated if she needed help, the nurses jump right in without being asked, and they get to us as fast as they can.

The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist. The facility initiated corrective actions prior to the initiation of the survey and concluded the corrective actions on 05/07/14. Those actions were as follows: re-training regarding searches to include search techniques, contraband, search of personal belongings post admission, searches were to be conducted in the quiet room/seclusion room, a secure area to ensure the search was captured on video, the video was monitored randomly throughout the day by administrative staff to ensure searches were being completed accurately, and entering the items on the Personal Belongings Inventory sheet. A complete search of all items in the donations closet was conducted and no contraband was found. Additionally, policies and procedures regarding safe environment included to be aware of the location of patients at all times, nurses were to be out in the milieu assisting and supervising the MHTs with direct patient care, levels of observations, conducting Q 15 minute checks on time, and document it was completed. Staff must make eye contact with each patient during the Q 15 minute check. When handing off patients, the person handing off the patient gives a report to the person accepting the patient book, and both must sign to signify a different staff was now responsible for the patient in the book. On 05/07/14, the facility discontinued the practice of special care where a patient was given a "time out" due to unacceptable behavior and was alone in their room for a specified length of time. On 05/07/14, the facility began using an Incentive Program for behavior modification which reinforces positive behavior by awarding points for following the rules and acceptable behavior. Patients who do not meet criteria for that day will attend an accountability group and write an essay about why the criteria was not met, so the patients were not left alone in their room. Patients have the opportunity to earn points on a daily basis to be used to earn different activities. All staff was given a competency test on everything covered.

The Immediate Jeopardy was determined to be abated on 05/12/14 prior to the exit of the survey.

Based on interview, medical record review, and review of the facility's policies and procedures, it was determined the facility failed to provide patients with nursing care which ensured the safety for one (1) patient (Patient #1), in the selected sample of ten (10) patients. The facility failed to adhere to their policies and procedures pertaining to routine searches of personal belongings after admission and as their policies pertain to Q 15 minute observations.

The Findings include:

Patient #1 received a pair of shorts post-admission which was not properly searched. An elasticized string was encased in the waistband and there was a slit in the waistband to allow the elasticized string to be pulled to tighten the garment. Additionally, he/she was placed on special care, and was required to remain in his/her room during free time following an outburst in the cafeteria. There was a miscommunication between a Mental Health Technician, (MHT) #2 and a Registered Nurse (RN) #6 which lead to MHT #2 being removed from direct patient care to complete another task, leaving MHT #9 to cover all of the patients in the unit. Due to the activity on the unit, MHT #9 missed the Q 15 minute check on 04/27/14 at 7:00 PM. As a result of the aforementioned failures, MHT #9 went to check on Patient #1, at approximately 7:11 PM, and found the patient lying on the bathroom floor with the elasticized string in the shorts wrapped around his/her throat. The string was crossed in the front and pulled up over his/her head.

These failures placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was identified and determined to exist related to Nursing Services; however, the facility initiated corrective actions prior to the initiation of the survey and removed the Immediate Jeopardy prior to the survey exit on 05/12/14.
Refer to A-395

Based on interview, medical record review, review of staff statements taken by the facility's Risk Manager, and review of the facility's policies and procedures, it was determined the facility failed to provide patients with nursing care which ensured patient safety for one (1) patient (Patient #1), in the selected sample of ten (10) patients. The facility failed to adhere to policies and procedures, entitled "Safe Environment", related to routine searches of personal belongings after visitation, and Levels of Observations/Special Precautions related to every fifteen (Q 15) minute checks. Patient #1 was admitted to the facility on 04/17/14 at 5:49 AM. Patient #1 was admitted to the facility after threatening suicide and putting a gun to his/her head. On 04/27/14 at approximately 5:00 PM, Patient #1 was placed on special care for a minimum of sixteen (16) waking hours, leaving him/her alone in his/her room. Patient #1 was placed on special care due to physical aggression toward a peer. During shift change at 7:00 PM, Mental Health Technician (MHT) #2 was allegedly removed from direct patient care by Registered Nurse (RN) #6, leaving MHT #9 with the responsibility of the eighteen (18) patients on the unit. MHT #9 missed the 7:00 PM Q 15 minute check on Patient #1 due to other activity on the unit. MHT #9 checked on Patient #1, at approximately 7:11 PM, and found him/her lying on the bathroom floor with the elasticized string in his/her shorts wrapped around his/her throat, crossed in the front, and pulled up over his/her head.

The Findings include:

Review of the facility's policies and procedures regarding "Safe Environment", revealed the policy required searches to be conducted on all patients and their belongings upon admission, as new personal belongings were brought in, and after visitation. Additionally, the policy stated "search after visitation/pass: items brought in by visitors for patient use will be searched prior to the patient's possession of these items."

Review of the facility's policy, "Levels of Observation/Special Precautions", revealed the policy required staff to conduct routine 15 minute checks (Q 15) on all patients. The policy stated, "Staff will make direct visual contact with the patient and document on the Patient Observation Round Sheet every 15 minutes. Hand off assigned "Patient Observation Sheets" to another staff member before leaving the patient treatment area (meals, breaks, emergencies)."

Review of the facility's policy, "Patient Belongings Inventory", revealed personal belongings were searched at the time of admission to ensure no contraband got to the unit. Additionally, the policy stated, when personal items for a patient were received from a visitor, the item(s) were identified with the patient's first name and last initial, and upon initial observation, any noted contraband will be returned to the visitor for removal from the facility.

Review of the facility's security video, dated 04/27/14 beginning at 6:25 PM, revealed the 7:00 PM Q 15 minute check was missed for Patient #1. MHT #9 entered Patient #1's room at 6:39 PM and exited at 6:41 PM. There was no evidence of activity observed on the video in Patient #1's room until 7:10 PM when MHT #1 checked on the patient. Between 7:12 PM and 7:35 PM, several staff entered and exited Patient #1's room. At 7:44 PM, Patient #1 was observed exiting his/her room with RN #11.

Review of staff statements provided to the facility's Risk Manager, revealed MHT #9 reported he had not completed the 7:00 PM Q 15 minute check on Patient #1. He was behind on the checks due to other activity on the unit, and he had all the other patients taken care of. The nurses were behind the desk during this time and would not take the book. MHT #9 reported he went to check on Patient #1 and found the patient lying on the floor in the bathroom and observed a string around his/her neck, which was crossed in the front of his/her throat and brought up over his/her head. A Code Blue was called, and he removed the string which was around the patient's throat, and other staff came to assist with the patient. MHT #9 also reported when he found Patient #1, he/she had a pulse but he did not notice any rise and fall of the patient's chest.

Review of the staff schedule, dated 04/27/14, revealed at 7:00 PM (shift change), there were six (6) RNs and four (4) MHTs (two MHTs for the boys and two MHTs for the girls) on the adolescent unit.

MHT #2 reported she gave her book (patient book) to MHT #9 because she was pulled from direct patient care by RN #6 to call the Department of Community Based Services (DCBS) regarding an allegation made by another patient. She stated there was no formal "hand off" of her patients. Additionally, she stated Patient #1 was on special care in his/her room. When she heard the Code Blue called, she responded and found Patient #1 with the string wrapped around his/her neck. Patient #1 had a strong pulse but appeared to not be breathing. Other staff arrived to assist and Patient #1 was revived. She took her book back from MHT #9 and noticed there were two (2) blanks on the Q 15 minute check sheet.

Patient #1 reported he/she was placed on special care, and was alone in his/her room which gave him/her time to think. Patient #1 reported he/she had not been checked on for ten (10) minutes and he/she used this time to attempt suicide. He/she removed his/her shorts and was folding them when he/she noticed the string, then took the string from the shorts, and wrapped it tightly around his/her neck and head while standing in front of the mirror, and recalled waking up on the floor. Additionally, Patient #1 stated he/she was not suicidal prior to the fight in the cafeteria. Patient #1 reported he/she believed the pair of shorts with the string was brought in to the facility on 04/26/14.

RN #4 reported she responded to the code. After the patient was stabilized, she contacted Patient #1's mother to explain what happened. Additionally, she reported she noticed the Q 15 minute sheet had blanks from 7:00 PM through 7:45 PM, so she initialed them as being done. She believed she had been with the patient during that time frame when she responded to the Code Blue.

Review of Patient #1's medical record revealed he/she was admitted to the facility on 04/17/14 due to threatening suicide while putting a gun to his/her head. At the time of admission, the patient was on Level II observations with suicide precautions. Review of nurse's notes revealed, on 04/27/14 at approximately 5:00 PM, Patient #1 physically attacked a peer in the cafeteria and was placed on special care for sixteen (16) waking hours. Review of the 7:19 PM nurse's note revealed, "the patient was found by the MHT with a string from his/her gym shorts tied around his/her neck, unresponsive, in the bathroom. The MHT called a Code Blue and untied the string from his/her neck. Patient #1 was breathing and had a strong pulse. Staff arrived and placed an ammonia capsule under his/her nose and the patient started to wake up. The patient's vital signs were taken. Initial vital signs were Blood Pressure (BP) 163/80 mm/hg, Pulse 83, Respirations (R) 20, and O2 Saturation 99 percent (%). The physician was notified and all required management was notified. Review of the nurse's notes, revealed, at 7:30 PM, "rechecked vitals. BP 118/55 mm/hg, Pulse 92, R 16, O2 99%". Patient #1 stated, "I had plenty of time to think about everything since I was alone in my room on special care. I have been upset and stressed about all the pain I have caused my family. The string I used was hidden in my gym shorts that could not be seen because it was sewn in the fabric." Patient #1 was placed on one (1) to one (1) care and remained with staff at all times. Continued to monitor the patient and maintain safety. Review of the Q 15 minute sheet revealed all fifteen (15) minute checks were documented as completed by RN #4, one of the RNs who responded to the Code Blue.

Interview with MHT #1, on 04/30/14 at approximately 2:55 PM, revealed she accepted three (3) pairs of shorts for Patient #1 on Saturday, 04/26/14 at approximately 3:30 PM. She conducted the search of the clothing and found strings in two (2) of the three (3) pairs of shorts, got permission to cut the strings out, actually cut the strings out, logged the clothing on Patient #1's "Personal Belongings Inventory Sheet", and gave the clothing back to Patient #1.

Interview with MHT #2, on 05/05/14 at approximately 10:40 AM, revealed she handed her book of patients off to MHT #9 after being removed from direct patient care by RN #6, leaving MHT #9 responsible for all eighteen (18) patients on the unit. She stated she responded to a Code Blue. She observed Patient #1 lying on the bathroom floor with a string pulled around his/her neck and the string was crossed in the front. She reported Patient #1 had a pulse but was not breathing at first. She stated she touched his/her rib area, and a nurse was doing a sternum rub on his/her chest. Then a nurse had an ammonia pack and waved it under the patient's nose and he/she started waking up.

Interview with RN #6, on 05/07/14 at approximately 12:38 PM, revealed she had clocked out, heard the Code Blue and returned to the unit to help. She put a blood pressure cuff and pulse oximeter on Patient #1 and told them to call the physician. She stated there were two (2) other nurses present. The patient started talking to the MHT, and the physician was notified. She told the nurses she had already clocked out and was leaving. Additionally, she reported she did not pull MHT #2 from direct patient care. She told her she would have to call DCBS before she went home and gave her the number to DCBS. MHT #2 asked MHT #9 to take her book and he said yes, and that was when she left the unit, and MHT #2 should have been back on the floor. RN #6 also stated she was unaware of any of the Q 15 minute checks being missed.

Interview with RN #4, on 05/07/14 at approximately 7:22 AM, revealed she was on the adult unit at the time of the incident. A Code Blue was called on the adolescent unit and she responded to the code. She stated, by the time she arrived, the shorts/string had been removed from around Patient #1's neck. Patient #1 was breathing, had a natural color, and a pulse. She reported his/her vitals were taken at at 7:15 PM, and she recalled this information because she looked at her watch, and wrote the time and the vital signs on her hand. She reported asking Patient #1 if he/she could hear her, and the patient responded yes. The patient was put on one (1) to one (1) observation. She stated she remained with Patient #1 until 7:45 PM. She reviewed the patient's chart, noticed the blanks on the Q 15 minute sheet from 7:00 PM to 7:45 PM, so she initialed the blanks because she was with the patient during that time while responding to the Code Blue.

Interview with the Risk Manager, on 04/30/14 at approximately 12:15 PM, and on 05/06/14 at approximately 9:35 AM, revealed while she reviewed the security video, dated 04/27/14, she noticed no staff had completed the 7:00 PM Q 15 minute check for Patient #1. She also reported MHT #9 told her he asked for help from the nurses. MHT #2 was pulled from direct patient care and he was involved with other patient activity which caused him to miss the 7:00 PM Q 15 minute check on Patient #1.

Interview with the Director of Clinical Services, on 05/06/14 at approximately 9:51 AM, revealed there was not a policy which defined special care. According to the Director of Clinical Services, the form used when a patient was put on special care best described what special care was, and the length of time the patient would be on special care. She also stated Patient #1 should have been better supervised.

Interview with RN #3, on 05/06/14 at approximately 2:34 PM, revealed she was on the 6:30 PM to 7:00 AM shift on 04/27/14. She reported the nurses were giving report and counting medications at shift change, and MHT #2 was on the phone, leaving MHT #9 to care for eighteen (18) patients. There was a lot of patient activity on the unit, and MHT #9 tried to watch the patients in the group room with all of the activity and missed the Q 15 minute check. She also stated a nurse could have assisted with the Q 15 minute checks.

MHT #9 was unavailable for interview due to a family emergency.

Review of re-training documentation, revealed all staff were re-trained on how to conduct searches of personal belongings, patient belongings inventory, patient hand off, and levels of supervision, beginning on 04/28/14. All staff were trained by 05/01/14.

Review of an e-mail sent from the Nurse Manager (RN #7), revealed the facility discontinued the practice of special care completely, effective 05/07/14, as any part of treatment for adolescent/child patients.

Review of the Patient Belongings Inventory policy with a revision date of May 2014 revealed all searches of personal belongings will be conducted in the quiet room/seclusion room, which was a secured area.

Interview with the Director of Nursing (DON), on 05/07/14 at approximately 12:19 PM, revealed he conducted re-trainings with the entire nursing staff which included all nurses, MHTs, the Scheduling Coordinator, and the ward clerk. The re-training included information about patient belongings, searches, inventory sheets, levels of observation, documentation basics, patient hand off, and imminent risk. Additionally, he reported nurses were to be out in the milieu assisting the MHTs with direct patient care.

Interview with the Chief Executive Officer (CEO) and the Risk Manager, on 05/07/14 at approximately 2:17 PM, revealed the Patient Belongings Inventory policy on searches was revised to state all searches will be conducted in a secured area.

Interview with the Director of Clinical Services, on 05/06/14 at approximately 2:22 PM, and on 05/07/14 at approximately 9:48 AM, revealed she reported the new Incentive Points program will focus on reinforcing positive behavior and will replace the current behavior modification program. The patient will not be in his/her room due to behavior issues. She reported the official end date of using special care was 05/07/14. This was discussed in the treatment team meeting which was attended by all physicians, therapists, nurse managers, the DON, and the assigned nurses. This information was posted on the units on the communications binder which required all nurses to read and provide a signature whenever they read it.

Interview with MHT #4, on 05/07/14 at approximately 3:00 PM, revealed she was re-trained to thoroughly complete searches of personal belongings, contraband, to double check clothing, that searches were only done in the quiet room/seclusion room, the levels of observation, to review any precaution levels of the patients, and ensure the whereabouts of the patients at all times. She stated as soon as we get our assignment sheet, get our eyes on the patients, and Q 15 minute checks must be completed timely. If we get pulled off direct care, we must hand off our book to ensure the Q 15 minute checks were done.

Interview with RN #7, on 05/07/14 at approximately 3:05 PM, revealed she had been off work and would be re-trained prior to beginning her shift. She stated the re-trainings were regarding search techniques, documentation, hand off communications, and Q 15 minute checks. She stated she never stayed behind the desk and the other nurses on her shift were also out with the patients in the milieu. She stated, "When I am on the unit, nurses were not behind the desk." Additionally, she reported the facility no longer used special care and they used the incentive program to reinforce positive behavior.

Interview with MHT #5, on 05/07/14 at approximately 3:09 PM, revealed she was re-trained on searches at the point of admission. When additional personal belongings were brought in for a patient, searches were completed in the quiet room/seclusion room only. MHT #5 stated we looked for contraband to include strings, wires, or anything a patient could use to harm himself/herself or others, and removed the contraband. Additionally, she reported the nurses were helpful if asked or when something was happening.

Interview with MHT #6, on 05/07/14 at approximately 3:14 PM, revealed she was re-trained on searches to look for anything that could be used by a patient to harm themselves or others, such as strings, pills, or contraband. MHT #6 stated searches could only be conducted in a secure area, the seclusion room. Document clearly, Q 15 minute checks, levels of observation, as well as the staff must lay eyes on the patient.

Interview with the Unit Clerk, on 05/07/14 at approximately 3:28 PM, revealed she had conducted searches of belongings and looked for anything that might be harmful, such as strings, pills, wires, or contraband. The Unit Clerk reported she was not currently responsible for any direct patient care; however, she completed the Q 15 minute checks on the patients prior to admission. She stated the patients remained in a locked room with the family or person who brought them to the facility and no cell phones, keys, or purses were allowed in this room. Those items were kept at the front desk.

Interview with MHT #7, on 05/07/14 at 3:33 PM, revealed he was re-trained on search techniques, contraband, and that searches must be conducted in the seclusion room. He further stated when belongings were brought to the facility, searches were completed before the patient had access to them. Regarding levels of observation and Q 15 minute checks, MHT #7 stated, "I have to hand off my book if I leave the unit. RNs were helpful on the unit and volunteered their assistance, not just when they were asked".

Interview with RN # 8, on 05/07/14 at approximately 3:45 PM, revealed he was re-trained on documentation, searches for contraband, personal belongings, and involvement with the MHTs regarding patient care. Additionally, he reported there was no longer a special care program, the incentive program took its place.

Interview with LPN #1, on 05/07/14 at approximately 3:51 PM, revealed she was re-trained on how to conduct searches, what to look for, Q 15 minute checks must be signed, whenever we hand off the book, we must sign it was handed off, and the person who accepted it signed as acceptance of the responsibility. We report any behavior changes, such as "no special care that ended today, and I help MHTs whenever possible with anything they need."

Interview with RN #5, on 05/07/14 at approximately 4:04 PM, revealed she was re-trained on conducting searches. RN #5 stated all personal belongings must be searched for contraband, strings, wires, and metal. The searches were conducted in the seclusion room, and items brought in after admission were also searched in the seclusion room. RN #5 stated, "I search clothing from the donations closet prior to issuing something to a patient." Every 15 minute checks were conducted by whomever was responsible for the patient, usually the MHT, but sometimes the nurses. Additionally, she assisted the MHTs voluntarily or when asked, and the facility no longer used special care.

Interview with the CEO, on 05/08/14 at approximately 10:30 AM, revealed his report revealed the donations closet items were completely searched, and no contraband was found.

Interview with the Risk Manager, on 05/08/14 at approximately 1:15 PM, revealed RN #11 called her, and stated he was with Patient #1 during the code until the patient was responsive.

Interview with RN #10, on 05/09/14 at approximately 12:03 PM, revealed she was re-trained on searches, personal belongings, inventory at admissions, and to search the seams of clothing. Searches were always conducted in the seclusion room. She stated staff search personal belongings when they were brought in for a patient, and were searched in the seclusion room. She stated we were out with the patients assisting the MHTs, doing Q 15 minute checks. She stated, "I do Q 15 minute checks depending on the need. When the MHT was busy, patient safety was first." Additionally, she reported special care was no longer used.

Interview with MHT #8, on 05/10/14 at approximately 11:21 AM, revealed she was re-trained on searches and the searches were always conducted in the seclusion room. Additional clothing post-patient admission was searched in the seclusion room also. The items would be placed on a patient personal belongs inventory list, and if anything seemed questionable, staff would not allow the patient to have it until approved by the nurse or the physician. The staff no longer implement special care, and now use the incentive program, which included Q 15 minute checks, and a visual check on all patients. MHT #8 stated if she needed help, the nurses jump right in without being asked, and they get to us as fast as they can.

The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist. However, the facility initiated corrective actions prior to the initiation of the survey and concluded the corrective actions on 05/07/14. Those actions were as follows: re-training regarding searches to include search techniques, contraband, search of personal belongings post admission, searches were to be conducted in the quiet room/seclusion room, a secure area to ensure the search was captured on video, the video was monitored randomly throughout the day by administrative staff to ensure searches were being completed accurately, and entering the items on the Personal Belongings Inventory sheet. A complete search of all items in the donations closet was conducted and no contraband was found. Additionally, policies and procedures regarding safe environment included to be aware of the location of patients at all times, nurses were to be out in the milieu assisting and supervising the MHTs with direct patient care, levels of observations, conducting Q 15 minute checks on time, and document it was completed. Staff must make eye contact with each patient during the Q 15 minute check. When handing off patients, the person handing off the patient gives a report to the person accepting the patient book, and both must sign to signify a different staff was now responsible for the patient in the book. On 05/07/14, the facility discontinued the practice of special care where a patient was given a "time out" due to unacceptable behavior and was alone in their room for a specified length of time. On 05/07/14, the facility began using an Incentive Program for behavior modification which reinforces positive behavior by awarding points for following the rules and acceptable behavior. Patients who do not meet criteria for that day will attend an accountability group and write an essay about why the criteria was not met, so the patients were not left alone in their room. Patients have the opportunity to earn points on a daily basis to be used to earn different activities. All staff was given a competency test on everything covered.

The Immediate Jeopardy was determined to be abated on 05/12/14 prior to the exit of the survey.