HospitalInspections.org

Based on document review, interview and observation the facility failed to ensure nursing staff followed facility policy related to suicide precautions/interventions during shower/toileting as evidenced by patient suicide attempt for 1 of 10 medical records (MR) reviewed. (Patient #1)

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, interview and observation the facility failed to ensure nursing staff followed facility policy related to suicide precautions/interventions during shower/toileting as evidenced by patient suicide attempt of 1 out 10 medical records (MR) reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Suicide", PolicyStat ID 18329665, last revised on 4/2023 indicated the following: POLICY: 6. INTERVENTION: Suicide Precautions (SP), Unit Staff - Maintain supervision of patients on suicide precautions during shower/toileting and remain at the bathroom door. Accompany patient as necessary, via same sex staff assignment, during bathroom use including shower/toileting.

2. Review of Patient #1's medical record indicated the following:
(a.) Patient #1 was voluntarily admitted to the Adolescent Acute Care Inpatient Unit on 6/15/25, transferred via EMS (Emergency Medical Services) to Facility #2 on 6/18/25 at 6:50 p.m. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent severe without psychotic features and suicide attempt.

(b.) Patient #1 had a HIGH RISK NOTIFICATION ALERT" sheet dated 6/15/25 at 2:38 a.m. and placed on suicide precautions due to suicidal ideation with a plan and self-harm precautions due to superficial cuts to wrist with rock.

(c.) A review of Patient #1's Psychiatric Evaluation dated 6/15/25 at 9:16 p.m. indicated the following: (He/She) continues to verbalize suicidal ideations. RISK ASSESSMENT: High. PLAN: The patient will be monitored closely on suicide, self-harm precautions.

(d.) A review of a "Code Blue RN (Registered Nurse) Documentation" dated 6/18/25 at 6:20 p.m. indicated the following: (Patient #1) was supposed to be taking a shower, (he/she) was found lying on the bathroom floor in the shower with leggings tied around (his/her) neck. RN ASSESSMENT: Conscious: No. Pulse: Yes. Breathing: Yes. EMS (Emergency Medical Services) Called: Yes. Time: 6:23 p.m. Called by: (N4, Registered Nurse). EMS Arrival Time: 6:30 p.m. Physical Assessment: Neurological: Unresponsive. Outcome: EMS Transport. Time: 6:50 p.m.

3. Review of an incident report for Patient #1 dated 6/18/25 indicated the following: Incident Date: 6/18/25 and Incident Time: 6:20 p.m. Shift: Second Shift. Incident Type: Suicide Attempt. Pre-incident mental status: cooperative. Type of Injury: Loss of Consciousness. Site of event: Location: Bathroom. Injury Caused By: Self Inflicted. Treatment or Intervention: Emergency Room. Name of Witness: (N5, Mental Health Technician). Comments on 6/18/25 at 11:57 p.m. indicated the following: (Patient #1) was in bathroom for hygiene time. When technician went to do check (Patient #1) did not answer and tech went into the pt's room and found Patient #1 lying on the shower floor with leggings tied around (his/her) neck. A code blue was then called.

4. A review of video camera footage of the Adolescent Acute Care Inpatient Unit hallway with A2 (Registered Nurse/Director of Nursing) and A4 (Regional Risk Manager) on 7/2/25 beginning at 1:00 p.m., an incident related to Patient #1 on 6/18/25 indicated the following: On 6/18/25 at 6:03 p.m., Patient #1 was observed to be standing outside of (his/her) patient room door in the hallway. N5 is observed letting (Patient #1) in (his/her) room for hygiene time. N5 then walked away to let other patients into their rooms for hygiene time. N5 walked by Patient #1's room on 6/18/25 at 6:08 p.m. and 6:09 p.m. but did not look in the patient's room. On 6/18/25 at 6:16 p.m., a total of 13 minutes since last 15 minute observation of (Patient #1) was completed, N5 goes to check on Patient #1, knocks on the patient's door a couple of times and then goes in and comes into the hallway and calls a code. No one was observed sitting at (Patient #1's) door to (his/her) room and/or enter before and/or after the patient's door was unlocked for (Patient #1) to enter to complete hygiene time. On 6/18/25 at 6:17 p.m., five nurses are observed running down the hallway to (Patient #1's) room, along with three Mental Health Technicians responding to (Patient #1's) room with two of the three standing outside of (Patient #1's) room. On 6/18/25 at 6:26 p.m., EMS arrived at (Patient #1's) room. On 6/18/25 at 6:28 p.m., additional EMS and police officers arrived. On 6/28/25 at 6:28 p.m., EMS were observed coming out of (Patient #1's) room with (Patient #1) on the gurney. EMS staff were observed to be looking at (Patient #1's) neck while walking down the hallway to exit the building.

5. During an interview with A2 on 7/1/25 at 11:55 a.m., A2 indicated that staff do not maintain supervision at a patient's bathroom door unless the patient is on a 1:1 observation. A2 indicated that the staff complete 15 minute observation checks by constantly walking through the hallways.

6. During an interview with A2 on 7/1/25 at 3:00 p.m., A2 verified the medical record information for Patient #1.

7. During an interview with N4 on 7/1/25 at 3:20 p.m., N4 (Registered Nurse) indicated that N5 had found (Patient #1) and called a code grey. N4 indicated that N3 was the second staff member in the patient room. N4 indicated that (he/she) observed N3 on the ground in (Patient #1's) bathroom attempting to get black pants that were tied around (Patient #1's) neck off. N4 indicated that Pt #1 was sent out right away via EMS (Emergency Medical Services). Pt #1 did not have a physician order for 1:1 observation but did have 15 minute observation checks. N4 indicated that the staff do not sit at a patient's bathroom door of patients who are on suicide precautions and 15 minute observation checks, but will knock on the pt's room door, get a verbal confirmation that they are okay and if no response will go in and check on the patient.

8. During an interview with N9 (Mental Health Technician) on 7/1/25 at approx. 3:30 p.m. N9 indicated that they do not sit at bathroom doors with patients who are on suicide precautions, and 15 minute observation checks during hygiene/shower/toileting time. N9 indicated that they would complete every 15 minutes observation checks by walking the hallways, knock on the patient's door to get verbal confirmation that the patient was okay, but do not sit at the door unless patient is on a 1:1 observation order.

9. During an interview with N5 on 7/2/25 at 2:10 p.m., N5 indicated that (he/she) had found (Patient #1) in the patient's shower on the floor when (he/she) was completing checks and knocked on the patient's door twice but did not hear anything, so (he/she) went inside the patient's room and found the patient in (his/her) shower on the floor with (his/her) back against the shower wall with something wrapped around (his/her) neck. N5 indicated that (Patient #1) was unresponsive and (he/she) had bloody mucous coming out of (his/her) nose. N5 indicated that EMS (Emergency Medical Services) arrived and transferred the patient to (Facility #2, Acute Care Facility). N5 indicated that no one was sitting at (Patient #1's) door during hygiene time. N5 indicated that (he/she) would knock on the patient doors and complete the 15 minute observation checks on the patients in their rooms.