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Based on record review and interview the hospital failed to ensure that patients hospitalized on the acute care psychiatric unit received care in a safe and therapeutic environment. The hospital failed to ensure a patient on a 1:1 observation status was not allowed to swallow a battery for 1 of 6 patients on 1:1 status out of a total sample of 8 patients who were patients on a 22 bed acute psychiatric unit. Findings:

Review of the medical record revealed Patient #1 was a 24 y/o female who was admitted to the hospital on 03/07/10 at 1645 (4:45 p.m.) per Physician's Emergency Certificate (PEC) legal status for Borderline Personality Disorder and Dangerous to Self. Documentation revealed that Patient #1's Axis I diagnoses included Major Depressive Disorder / Severe with Psychosis with Mixed Substance Abuse.

Further review of the medical record revealed prior to admission to the psychiatric hospital, Patient #1 stabbed herself in the stomach with a butcher knife while at home and when in Hospital " A " Emergency Dept., Patient #1 attempted to strangle herself with a roll of Kerlix gauze. Review of the medical record revealed that Patient #1 was stabilized, and the patient was transferred and admitted to the psychiatric hospital.

Review of Patient #1's Initial Nursing Assessment dated 03/07/10 at 1645 (4:45 p.m.) reflected that Patient #1 was respectful and appropriated while interacting with staff during interview.

Review of Multidisciplinary Notes dated 03/08/10 at 0925 (9:25 a.m.) revealed an entry to reflect that Patient #1 was in the hallway with active bleeding noted to the right arm from a self inflicted laceration. Further review revealed that 911 was called and Patient #1 transported to Hospital " A " Emergency Dept. accompanied by a Mental Health Tech (MHT).

Review of Multidisciplinary Notes dated 03/08/10 at 1500 (3:00 p.m.) reflected Patient #1 returned to the unit in stable condition.

Review of Patient #1's Physician Orders reflected an order dated 03/08/10 at 0925 (9:25 a.m.) to " Place on 1:1 " observation status. Patient #1 remained on 1:1 observation status until 03/19/10. Review of Physician Orders dated 03/19/10 reflected an order " 1. D/C 1:1 status & D/C Room restrictions, no longer at risk 2. Line of sight observation. "

Review of the Hospital's Policy on 1:1 status, defined 1:1 status as a status in which the patient would be continuously observed, and the patient must remain within arms length of a staff member at all times. The policy reflected that while a patient is on 1:1 status, the staff member would be responsible for that patient only.

Interview with S2, Registered Nurse (R.N.), on 04/01/10 at 11:12 a.m. confirmed that Patient #1 was on 1:1 status and had phone privileges. S2, R.N., reported that Patient #1 manipulated the phone, removed a battery from the phone during phone time, swallowed it and then informed S3, MHT that she had swallowed the battery.

S2, R.N. stated that she and S3, MHT examined the phone and one of the two batteries was missing. S2, R.N. reported that the physician was informed and Patient #1 was sent to Hospital " A " where it was confirmed by X-ray that the patient had swallowed one " aa battery " .

Interview with S4 MHT on 04/01/10 at 10:49 a.m. revealed that she was the MHT responsible for 1:1 observation of Patient #1. S4, MHT reported that she left the patient in the care of S3, MHT while the patient was talking on the telephone. S4, MHT reported that she was gone no longer than 5 minutes and when she returned to the unit, she was informed by S3, MHT that Patient #1 had swallowed one of the batteries from the telephone.

S3, MHT was interviewed on 04/01/10 at 12:53 p.m. S3, MHT confirmed that S4, MHT requested her to assume 1:1 responsibility of Patient #1 while she (S4) went to the bathroom. S3, MHT reported that Patient #1 was using the telephone during this time. S3, MHT stated that she stood next to the patient during the phone conversation, and the patient told her that she had just swallowed a battery. S3, MHT indicated that S2, R.N. intervened and notified the patient's physician. S3, MHT reported that the patient was sent to the hospital by ambulance and escorted by an MHT.