HospitalInspections.org

Based on policy review, medical record review, video review, document review, and interview, in one of 17 medical records reviewed, it was determined the hospital failed to protect and promote the rights of all patients. Specifically, staff failed to conduct routine 15-minute safety checks on 07/17/25, which resulted in an attempted suicide by hanging using a sheet (Patient #1).

Reference:
482.13(c)(2): The patient has the right to receive care in a safe setting.

Based on medical record, policy, document reviews, and interviews, the hospital failed to ensure the quality assessment and performance improvement program conducted a data-driven quality assessment and implemented performance improvement activities to prevent and reduce adverse events for an identified sentinel event (Patient #2).

Reference:
482.21(a), (c)(2), (e)(3): Patient safety.

Based on document, policy, medical record, and video review, and interviews, it was determined that in one of 17 medical records reviewed that the hospital failed to ensure Patient #1 received care in a safe setting.
1. On 07/17/25 from 05:33 PM to 05:50 PM, staff failed to conduct routine 15-minute safety checks (random checks by staff every 15 minutes) for Patient #1, which entails face-to-face patient verification and location confirmation, and a check of all areas and doors. Failure to conduct the 15-minute check resulted in an attempted suicide by hanging using a sheet.
2. Clinical staff failed to document special observation #2 monitoring (SO2- patient in view of assigned staff at all times) every 15-minutes for Patient #1. The registered nurse (RN) did not sign off each shift to indicate they reviewed the SO2 monitoring sheet to ensure the staff member assigned to observe Patient #1 initialed/completed the document. The Registerd Nurse Supervisor did not ensure SO2 documentation was completed daily.

Findings #1:

Review of the orientation training "Patient Safety Education," no date (prior to the event), revealed rounds are completed by all staff (RN, Licensed Practical Nurse (LPN), Secure Care Therapy Aid (SCTA), and Mental Health Therapy Aid (MHTA), and documented every 15 minutes. Rounds are to be completed on a timely basis.

Review of the policy "Unit Rounds," revised 04/2025, indicated unit rounds are a tour of the entire unit when the designated staff member enters all rooms, including private and semi-private rooms, to visually verify the whereabouts, face to face, of all patients and their condition; ensure the count is correct throughout the shift; identify existing or potentially hazardous or non-therapeutic conditions; check all required areas and doors to ensure that they are locked, there are no obstructive objects in the locks, and that strobe light/motion detectors are in the on position; and check that all bed alarms are functioning properly. Unit rounds include a verification of each patient's location and that the unit census for that shift is verified through visualization of each patient. The daily assigned staff member are to complete unit rounds every 15 minutes and the RN periodically accompanies assigned staff to ensure procedures are followed.

Review of the medical record for Patient #1 revealed on 05/30/25 at 10:00 AM, Patient #1 was transferred to this psychiatric hospital for schizophrenia with paranoia and delusional thoughts. From 07/16/25 at 09:25 PM until 07/17/25 at 05:50 PM, routine 15-minute safety checks (random checks by staff every 15 minutes) were ordered for Patient #1. At 05:45 PM, Staff (J), Mental Health Therapy Aide (MHTA), documented a routine 15-minute safety check. At 05:51 PM, Patient #1 was found on their bedroom floor unresponsive due to an attempted suicide via hanging using a bedsheet over the door. Cardiopulmonary Resuscitation (CPR) was initiated. Patient #1 regained breathing and a pulse but remained unconscious but responsive to painful stimuli. Patient #1 was transferred to another hospital by ambulance with paramedics.

Review of video surveillance, dated 07/17/25 of 5-South/Northeast hallway, revealed the following:
-At 05:30 PM, Staff (J), MHTA, was seen sitting in the hallway on a rolling chair between the dayroom and the nurses' station on the same side of Patient #1's room (assigned to monitor the hallway and complete routine 15-minute patient safety checks).
-At 05:39:41 PM, Staff (J), MHTA, walked into the nurse's station, concurrently when Patient #1's door opened. A hand is seen holding a blue blanket over the top door corner, as the door closed.
-At 05:40:27 PM, Staff (J), MHTA, exited the nurse's station with a clipboard, passed Patient #1's door. Staff (J), MHTA, did not appear to look at Patient #1's door, before proceeding down the back hallway out of view.
-At 05:41:08 PM, Staff (J), MHTA, returned to view walking from the back hallway towards the nursing station. A blue blanket can be seen hanging on the top corner of Patient #1's door.
-At 05:43:12 PM, Patient #1's door opened. The blue blanket disappeared, and a white knotted sheet was seen hanging over the corner of the door. Patient #1' s door closed.
-At 05:44:27 PM, the white knotted sheet hanging over Patient #'1's door was moved to a higher position on the door.
-At 05:45:12 PM, Patient #1's door opened, a white sheet can be seen being lowered toward the exterior door handle area, adjusted, with knot at the end. A hand was seen pulling the white sheet lower, and then door closed. Patient #1's door opened, then closed. Patient #1's door opened, and the white sheet is not seen. Patient #1's door opened, and sheet the white sheet re-appeared. A patient with a ponytail and glasses walked by Patient #1's door and looked at it as it closed, revealing the white sheet.
-At 05:46:01 PM, Staff (K), MHTA, walked by Patient #1's door toward the rear hall, the white sheet is seen on the door. Staff (J), MHTA, was seen in the hallway sitting on a rolling chair near day room. Staff (K), MHTA, walked by Patient #1's door from the rear hallway carrying linen. The white sheet is seen on Patient #1's door.
-At 05:48:11 PM, Staff (K), MHTA, walked toward the back hall past Patient #1's door, the white sheet is seen on the door. Staff (J), MHTA, was seen in the hallway in a rolling chair.
-At 05:49 PM, Staff (L), MHTA, walked by Patient #1's room, looked directly at Patient #1's door, and continued to walk toward the rear hall. Staff (L), MHTA, looked back at Patient #1's door two times then entered a door off the hallway. Staff (J), MHTA, is seen sitting in the hallway in a rolling chair near the day room..
-At 05:50:01 PM, Staff (L), MHTA, exited through a door off the rear hallway pushing a cart, walked past Patient #1's door, and looked directly at the door. Staff (L), MHTA, turned left and walked out of view with the cart toward the nurse's station. Staff (I), MHTA, went to Patient #1's door with a key to open it. The door was partially opened. Staff (H), RN, was behind them. Staff (J), MHTA, arrived at Patient #1's door. When the door opened, Staff (I), MHTA, left the area. Staff (H), Registered Nurse, entered the room.
-At 05:52 PM, other staff arrived at Patient #1's room with the crash cart. Multiple staff are seen running to the room.

An interview on 07/24/25 at 09:18 AM with Staff (B), Hospital Administrator, revealed that upon reviewing the video, Staff (J), MHTA completed the 05:45 PM safety check from the hallway and did not see the Patient #1 in their bedroom.

Findings #2:

Review of the policy "Special Observation," revised 07/2024, established two different levels of special observation: Level SO1- one-to-one constant observation; and Level SO2- in view of staff observation. The RN will utilize the daily assignment sheet to assign a staff member to observe the patient for no more than two hours before being relieved. The RN ensures that the staff member assigned to observe the patient initiates and completes the "Special Observation Monitoring Form." Once per shift, the RN personally observes the assigned staff for compliance with the policy and procedure by initialing the staff signature block on the "Special Observation Monitoring Form." The assigned unit staff initiates and completes "Special Observation/Risk Reduction Order Form." The assigned unit staff ensures that a SO2 patient is not left unattended until assigned relief has arrived. The RN supervisor reviews all "Special Observation Monitoring Forms," daily to ensure that policy and procedures have been followed and takes immediate corrective action when deficiencies are identified.

Review of the policy "Unit Rounds," revised 04/2025, indicated a daily log of unit rounds be maintained reflecting employees responsible and their initials/signatures signifying the completion of such rounds at designated times periods. The Charge Nurse and the RN are responsible for monitoring the completion of unit rounds to ensure compliance with this policy. This is initiated by the responsible employee on the daily unit rounds log at designated times. The unit rounds log is completed during all rounds on each shift. Completed forms are submitted to the Charge Nurse Office at the end of each shift. Unit rounds are performed by the RN, LPN, Secure Care Treatment Aide (SCTA), and MHTA, as designated on living unit assignment sheets. The daily assigned staff member are to complete unit rounds every 15 minutes and the RN periodically accompanies assigned staff to ensure procedures are followed. The RN makes unit rounds twice per shift and initials at the time of completion. Round sheets must be brought to the Charge Nurse Office at the end of each shift. It is the responsibility of the Charge Nurse to ensure that RNs are assigning, scheduling, and enforcing the completion of unit rounds on each shift at designated intervals. They are to ensure that administration is advised of any difficulties observed during unit rounds which need administrative action. The RN confirms that joint unit rounds are conducted by Unit Charge RN and assigned staff of each living unit at shift change. The Charge Nurse will check the rounding board to ensure it is up to date, ensure strawberry motion is on with visual check of "on" indicator on nights, ensure completed reports are submitted to each shift, and ensure two staff are assigned to monitor hallways at all times each shift. Staff should be stationed next to the nurse's station hall to ensure that any patient entering or exiting a bedroom will be observed by staff.

Review of the medical record for Patient #1 revealed SO2 monitoring was ordered from 06/04/25 to 07/10/25, and on 07/16/25 from 03:35 PM to 09:24 PM due to paranoid ideation, thoughts of self-harm, aggression, and a history of suicidal behaviors.

Review of the medical record monitoring documentation for "Special Observation 2 (SO2- patient in view of an assigned staff at all times)" for Patient #1 revealed the following:
-From 06/28/25 at 06:51 AM to 06/29/25 at 01:59 AM, there was no clinical staff documentation of SO2 monitoring except on 06/28/25 at 03:32 PM when a RN documented SO2 monitoring remained in place.
-From 07/01/25 at 07:46 AM to 07/02/25 at 01:44 AM, there was no clinical staff documentation of SO2 monitoring.
-From 07/02/25 at 03:46 AM to 07/03/25 at 07:44 PM, there was no clinical staff documentation of SO2 monitoring, except on 07/02/25 at 12:55 PM, when a RN documented that Patient #1 remained on SO2 for paranoid ideations.
-From 07/08/25 at 03:46 AM to 11:44 AM, from 07/09/25 at 07:46 AM to 07:54 PM and from 07/10/25 at 08:46 AM to 10:30 AM, there was no clinical staff documentation of SO2 monitoring.
(No evidence was found to indicate the nursing supervisor reviewed the SO2 documentation daily and implemented corrective actions for incomplete documentation).

Review of the medical record monitoring documentation for "Special Observation 2 (SO2- patient in view of staff at all times)" for Patient #1 revealed the RN did not sign off each shift to indicate they reviewed the SO2 monitoring sheet to ensure the staff member assigned to observe Patient #1 initialed/completed the document on the following days:
-The day shift RN on 06/04/25, 06/05/25, 06/08/25 to 06/13/25, 06/15/25 to 06/18/25, 06/20/25 to 06/22/25, 06/24/25, 06/25/25, 06/27/25, 06/28/25, 06/30/25 to 07/02/25, 07/04/25, 07/06/25, 07/08/25 to 07/10/25, and 07/16/25.
-The night shift RN on 06/12/25, 06/14/25, 06/21/25, 06/28/25, 07/01/25, 07/10/25, and 07/16/25.
(No evidence was found to indicate the nursing supervisor reviewed the SO2 documentation daily and implemented corrective actions for incomplete documentation).

Interview on 07/24/25 at 09:18 AM with Staff (B), Hospital Administrator, verified these findings.

Based on medical record review, policy review, document review, and interview, the hospital failed to investigate and analyze an adverse/sentinel event (Patient #2) and implement corrective actions and mechanisms to prevent further occurrences. Specifically:
1. The hospital did not identify how the plastic bag was obtained, and did not identify the staff member who allowed Patient #2 to utilize a handicap bathroom unattended.
2. Administration/Quality Assessment and Performance Improvement (QAPI) Program did not review the implemented auditing for effectiveness.
3. Corrective actions implemented by the hospital did not include the need for physical/visual monitoring of patients during rounding, inspection of patients when returning to the unit, the inspection of food items left in the waiting room, and the inspection of patient items prior to use in private areas.

Findings include:

Review of the medical record for Patient #2 revealed on 11/13/24 at 09:45 AM, they were admitted to the facility for making suicidal threats with a plan while in jail. Patient #2 had a history of Schizoaffective disorder with multiple inpatient hospitalizations. Patient #2 denied any suicidal thoughts or ideations but had a history of several previous suicide attempts including an attempt to choke self in the shower, and an attempt to hang self with shoestrings during theirs last facility hospitalization in 2013. From 11/29/24 at 04:30 PM to 12/10/24 at 02:54 PM, Patient #2 was on special observation 2 (SO2). On 12/10/24 at 08:15 PM, SO2 was discontinued by the treatment team. Routine observations continued every 15 minutes by staff per facility policy. On 06/01/25 at approximately 10:32 AM, Patient #2 was found by the housekeeper on the floor of the handicapped shower with a clear plastic trash bag over their head, pulseless and with no spontaneous breaths. Patient #2's lips appeared blue, and extremities were pale and dusky with slightly cyanotic fingertips. A code was called but Patient #2 did not regain a pulse or electrical activity. The time of death was 11:13 AM.

Findings #1:

Review of the policy "Sentinel Event," revised 01/16/24, revealed that if a sentinel event occurs, the facility has a process to ensure such events are reported and investigated in a timely manner. This includes a thorough process for analyzing the sentinel event information to understand the causes and to make changes to prevent patient harm from recurring. Any event in which an area of serious risk has been identified, the facility must conduct a root cause analysis (RCA- identifying the main contributing factors of the event and potential solutions) or apply a different tool. RCA's must be completed within 45 days of the discovery of the sentinel event.

Review of the Unit 76 staffing schedule, dated 06/01/25, revealed the following staff were on duty during the suicide event for Patient #2: Staff (Z), Registered Nurse (RN), Staff (GGG), Mental Health Therapy Aide, Staff (EEE), Mental Health Therapy Aide, Staff (FFF), Mental Health Therapy Aide, and Staff (HHH), Mental Health Therapy Aide. Interviews on 08/06/25 and 08/07/25 with these staff members revealed that a key is needed to enter the handicap shower room and none of the staff knew who let Patient #2 into the handicap shower room unattended.

Review of facility quality assurance documents, dated 06/24/22, revealed no evidence to indicate which staff member allowed Patient #2 into the handicap shower room unattended. No evidence was found to indicate the staff members responsible for monitoring Patient #2 on 06/01/25 received additional re-education and/or supervision following the suicide event for Patient #2 to ensure they have a sufficient understanding of responsibilities/policies related to patient monitoring, to prevent a recurrence.

Interview on 07/25/25 at 08:40 AM with Staff (B), Hospital Administrator, revealed the event remains under investigation by the New York State Justice Center (a New York State agency that has authority to investigate all reports of abuse and neglect in covered facilities and programs, pursue administrative sanctions against staff found responsible for misconduct, and its Special Prosecutor/Inspector General that collaborates with local District Attorneys to prosecute criminal offenses involving allegations of abuse or neglect). The hospital has not conducted an investigation and/or RCA. It is unknown how the plastic bag was obtained by Patient #2 and which staff member let Patient #2 into the handicap shower.

Findings #2:

Review of audit forms for "Daily Rounding for Plastic Bags," revealed the following:
-From 06/04/25 to 06/27/25, Environmental Services (EVS) staff rounded daily in the housekeeping closet and cart on all in-patient units, the clinic area, patient café (located on the first floor), and the supply building for plastic bags.
-From 06/05/25 to 07/13/25, the registered nurses on each unit rounded daily in all patient areas for plastic bags and if biohazard bag were locked in the designated cabinet.
-From 06/05/25 to 07/24/25, the Treatment Team Leader rounded daily in each unit checking for plastic bags in non-patient areas and programing space.
-From 06/05/25 to 07/08/25, Safety Officers rounded daily at the building entrance, visitation room, facility main waiting room/lobby/bathroom, and vending area for plastic bags.

Review of facility quality meeting minutes dated 06/24/25 revealed the facility discussed the immediate actions taken which included removing plastic bags from all patient areas, locking up biohazard bags in the treatment rooms on the units, a process for handling patient packages, a mitigation plan, the use of handicap bathrooms, and updating the rounding log. There was no documented discussion or analysis of the audit's findings.

Interview on 08/06/25 at 02:00 PM with Staff (B), Hospital Administrator, revealed the plastic bag audits were not reviewed by the team.

Findings #3:

Review of the policy "Visiting Policy," revised 01/14/25, revealed visitors will be asked to leave all packages and purses in secure lockers outside of the entrance. Unit staff will accept packages for patients and be notified when visitors are bringing food to the unit for patient consumption. (This policy does not address the need to inspect all food/beverages and/or packages for safety prior to bring on the unit and/or giving them to the patient).

Review of the policy "Search of Inpatients and Visitors," revised 02/18/25, revealed that approval must be obtained from the clinical director/designee or the on-call physician for all patient searches. A search can include a body search, cavity search metal detector search, pat search, and room/property search. Routine searches of patients are included for all newly admitted patients, all patients returning to an in-patient unit following an unescorted leave, and at the initiation of all restraint and seclusion orders. The routine search of patients returning from unescorted leave procedure by the safety officer includes using a metal detector (wand), emptying their pockets, or opening packages if there is a reason to believe the individual is attempting to bring in contraband.

Review of the policy "Unit Rounds" revised 04/2025, indicated unit rounds are a tour of the entire unit where the designated staff member enters all rooms, including private and semi-private rooms, to visually verify the whereabouts, face to face, of all patients and their condition; ensure the count is correct; identify existing or potentially hazardous or non-therapeutic conditions; ensure the security of the unit by checking all required areas and doors to ensure that they are locked, there are no obstructive objects in the locks, and that strobe light/motion detectors are in the on position; and to check that all bed alarms are functioning properly. The unit rounds log is completed every 15 minutes on each shift, initialed by the responsible employee, and submitted to nursing office at the end of each shift. Unit rounds can be performed by all staff designated on living unit assignment sheets. The RN periodically accompanies assigned staff to ensure procedures are followed. The RN makes unit rounds twice per shift and initials at the time of completion. The nursing supervisor will check the rounding board each shift for completion and that two staff are assigned to monitor the hallways at all times. Staff should be stationed next to the nurse's station hall to ensure that any patient entering or exiting a bedroom will be observed by staff.

Review of facility quality meeting minutes, dated 06/24/25, revealed the facility discussed the immediate actions that was taken which included removing plastic bags from all patient areas, locking up biohazard bags in the treatment rooms on the units, process for handling patient packages, update of mitigation plan, the use of handicap bathrooms, and updating the rounding log. Despite administration not identifying how the plastic bag was obtained and who opened the handicap shower door leaving Patient #2 unattended, there is no evidence to indicate corrective actions included staff reeducation and auditing on established policies and procedures related the need for routine searches of patients who leave the unit unescorted and 15-minute rounding checks to include visual verification of the patient and environment, and that two staff are monitoring the hallways to ensure patients entering and exits rooms. Additionally, it is unclear who is responsible for inspecting food deliveries to remove plastic bags and/or other contraband from document and policy review.

Interview on 07/25/25 at 08:40 AM with Staff (B), Hospital Administrator, revealed that following the event, corrective actions were implemented which focused on removing plastic bags from patient areas and re-educating staff on how to properly fill out the unit rounding logs.