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Based on observation, record review and interview the facility failed to ensure the safety of patients as evidenced by:

1. Every 15 minute Close Observation Rounds were not made on 11 of 11 patients (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and Patient #12).
2. Suicide precautions were not reassessed and reordered every 24 hours on 5 of 6 patients (Patient #1, #14, #15, #16 and Patient #17).

Findings included:

TX 00227939

1. Close Observation Rounds

Observation of the Adult Psychiatric Unit on 01/06/2016 at 0900 revealed Psychiatric Care Assistant (PCA) #55 in the common area talking with several patients

Record review of the every 15 minute Close Observation Rounds sheets on 01/06/2015 at 0905 revealed 11 of 11 round sheets had not been completed in a timely manner. The Close Observation Records were incomplete:
· 6 records for 30 minutes (Patients #2, #7, #8, #9, #10 and Patient #12),
· 1 record for 45 minutes (Patient #5),
· 2 records for 1 hour (Patient #3 and Patient #4),
· 1 record for 1 hour 15 minutes (Patient #6), and
· 1 record for 1 hour 45 minutes (Patient #11).

In an interview with PCA #55 on 01/06/2015 at 0905, she stated the rounds are supposed to be completed and documented every 15 minutes. She stated she was behind on the rounds because she had been busy getting patients back to the unit.

In an interview with Director of Nursing (DON) #53 and Quality Manager (QM) #52 on 01/07/2016 at 1100, they stated that rounds are to be made on patients every 15 minutes and documented on the Close Observation Rounds sheets.

Record review of the Policy, Rounds for Patient Observation, dated 06/2015 revealed: " An accurate record of the whereabouts of all patients on the Inpatient unit will be maintained during each shift ... 5. Every patient must be seen by a staff member every 15 minutes during the day and evening, unless otherwise ordered as line of sight or 1:1, during the night and checked off on the Observation Sheet as present. This includes when patients are in groups, or off unit activities. The assigned parson is still responsible to document the patient ' s whereabouts ... "

2. Suicide Precautions

Record review of patient charts revealed that 6 of 6 patients (Patient #1, #13, #14, #15, #16 and Patient #17) were ordered suicide precautions. 5 of 6 patients (Patient #1, #14, #15, #16 and Patient #17) did not have their suicide precautions reassessed every 24 hours for renewal or discontinuation.

In an interview with Medical Director #70 on 01/07/2016 at 1310, he stated suicide precautions are to be reassessed every 24 hours per policy. He also stated the physician determines every 24 hours if the precautions are to be reordered or discontinued.

In a phone interview with RN #64 on 01/07/2016 at 1010, she stated that suicide precautions are to be renewed every 24 hours. She also stated that the night nurse writes down the precautions on the physician ' s orders in the chart so the physician can renew or discontinue them. " Chart checks are done every morning. "

In an interview with DON #53 on 01/07/2016 at 1100, she stated, " The nurse is to remind the doctor of patients on suicide precautions ... Corporate has asked us not to flag charts for renewal of precautions ... we just started re-educating nurses not to do that. The nurse can put it on a sticky note. They are not to write an order. There ' s no system in place for the RN to prompt the doctor about renewal of precautions. "

In an interview with CEO #51 on 01/07/2016 at 1100, she stated that the inconsistencies in how precautions get renewed or discontinued would be cleared up. She did not want reminders to renew or discontinue precautions written on sticky notes.

Record review of Policy, Suicide Precautions, dated 01/2012, revealed: " To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients ... 2. Suicide precautions are ordered for a maximum of 24 hours and reassessed each 24-hour period for renewal ... "

Based on observation, record review and interview the facility failed to ensure the completion and/or follow through of the discharge process as evidenced by:

· The Discharge Suicide Risk Assessment was not done for 1 of 5 patients (Patient #14).
· The physician was not notified of an out of range score on the Basis 32 for 1 of 5 patients (Patient #1).
· The Basis 32 was not done on 1 of 5 patients (Patient #16).
· There were procedural discrepancies in the follow through for out of range scores on the Basis 32 and Suicide Risk Assessment for 1 of 1 staff (RN #64).

Findings included:

TX 00227939

Record review of Behavior and Symptom Identification Scale Basis 32 for Patient #1 on 10/26/2015 [not timed] revealed: The instructions direct the participant to " fill in the box that best describes the degree of difficulty you have been experiencing in each area during the past week. " On items 6 (adjusting to major life stresses) and 9 (isolation or feelings of loneliness, " she scored " quite a bit. " She scored " extreme " to item 17 (depression, hopelessness).

Record review of Discharge Safety Plan by RN #64 dated 10/26/2015 at 1400 revealed:
· " Discharge Suicide Risk Assessment ... 1. On the Basis 32 did patient respond " Quite a bit " or " Extreme " to questions 9, 16, 17, 18, 20, 22, or 31? [Answer:] ' Yes '
· 2. Does the patient report any suicidal ideation at the time of discharge? [Answer] ' No '
· PHQ-2 - Over the past 2 weeks, how often have you been bothered by any of the following problems?
o Little interest or pleasure in doing things - several days - score of 1
o Feeling down, depressed or hopeless - not at all - score of 0
o Total - 1
· If you answered yes to question 1 or 2 or the patient scored a 3 or greater on the PHQ-2, notify the provider prior to discharging the patient.
· 3. A commitment to Live has been reviewed with the patient which includes the hospital phone number in the event that suicidal thoughts occur. ' Yes. ' "

In an interview with RN #64 on 01/07/2016 at 1000, she stated she thinks she called Director of Clinical Services (DCS) #62 to tell her that Patient #1 stated she was hopeless and depressed at the time of discharge. She also stated she did not phone the MD #59 but " both therapist and physician are to be notified. "

In an interview with MD #59 on 01/07/2016 at 1120, he stated he was not notified by RN #64 or any other staff member that Patient #1 had verbalized feelings of hopelessness at the time of discharge. He stated, " I may have kept the patient another day had I been notified of the Basis 32 score. "

In an interview with DCS #62 on 01/07/2016 at 1150, she stated she did not get a call from RN #64 about the Basis 32 score on Patient #1.

In an interview with Quality Manager (QM) #52 on 01/06/2016 at 1515, he stated that the phrase " notify the provider prior to discharging the patient " found on the Discharge Risk Assessment form means to notify the physician. He stated the documentation of this action " should be in a progress note. " He also stated he could not find any documentation that RN #64 notified the physician that Patient #1 stated she felt hopeless.

In an interview with DON #53 and QM #52 on 01/07/2016 at 1100, they stated the Basis 32 is to be done on all patients discharging. QM #52 stated he could not find a policy that addressed the Basis 32. DON #53 and QM #52 also stated the Discharge Suicide Risk Assessment form should identify the " provider " as the physician and provide space for the nurse to document any interaction with the physician when the patient is found to be suicidal upon discharge.

Record review of 5 patient charts (Patient #1, #13, #14, #15 and Patient #16) revealed that the Basis 32 was not done on Patient #16. The Discharge Suicide Risk Assessment was not completed on Patient #14. As noted above, the physician was not notified of Patient #1 ' s hopelessness at the time of discharge.