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Based on interview and document review the Condition of Patient Rights is not met.

Based on interview and document review the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when she was on constant staff supervision, wrapped a torn piece of clothing as a ligature around her neck, and attempted to strangle herself. Multiple staff were in attendance and did not intervene. In addition, while P1 was to be on constant staff supervision she used a staple to cut herself when staff were not present, then swallowed the staple. See A144.

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when she was on constant staff supervision, wrapped a torn piece of clothing as a ligature around her neck, and attempted to strangle herself. Multiple staff were in attendance and did not intervene. In addition, while P1 was to be on constant staff supervision she used a staple to cut herself when staff were not present, then swallowed the staple.

Findings include:

P1's History and Physical dated 3/2/20, indicated P1 was admitted to the hospital's adolescent mental health unit on 3/2/20, with diagnoses that included borderline personality disorder, and major depressive disorder severe with psychotic features. P1 had a history of violence and suicidal ideation. Prior to admission, P1 had recently tied a shoelace around her neck in a suicide attempt, and ingested metal while at her group home.

Emergency Department (ED) notes dated 3/2/20, indicated that while P1 was at the hospital's ED, she had ingested a battery.

On 3/3/20, P1's Physician Orders indicated P1 was admitted to the hospital with diagnoses including suicide attempt under Status Individual Observation (SIO, meaning she had a staff member dedicated to watching her alone, in order to maintain her safety).

On 3/17/20, a progress note indicated while P1 was on SIO she ripped her scrub top and tied it around her neck. P1 was placed on SIO with 2 staff to 1 patient.

On 4/1/20, a progress note indicated P1 ripped her scrub top, and wrapped a torn piece of the top around her neck. P1's neck was red and swollen afterwards.

On 4/2/20, a progress note indicated P1 had red marks from the ligature the following day.

On 4/14/20, a progress note indicated P1 was still on SIO 2:1 staffing, and she was in the bathroom alone, unobserved. After she was "in the bathroom for some time," staff decided to check on her, and found her with a staple cutting herself. P1 then swallowed the staple.

On 4/14/20, at 1:25 p.m. registered nurse (RN)-D was interviewed and stated he entered P1's room on 4/1/20, and saw P1 was under her desk. RN-D stated there were two other staff in the room. RN-D stated P1 ripped her scrub top and put it around her neck. RN-D stated he heard P1 rip her clothes and saw her moving her hands, but did not intervene to stop her from putting it around her neck. RN-D stated staff waited for security to arrive to remove the ligature around P1's neck. RN-D stated he did not know how long the ligature was around P1's neck, but thought it was less than 5 minutes.

On 4/14/20, at 1:40 p.m. RN-E was interviewed and stated that on 4/1/20, P1 was upset, went into her room, and went under her desk. RN-E stated she could hear P1 ripping her clothes, and P1 wrapped her pieces of clothing around her neck as a ligature. RN-E stated although staff were in the room with P1 when she placed the ligature around her neck, no staff intervened to stop her because P1 could be violent. Instead, staff waited for security to intervene. RN-E was not sure how long P1 had the ligature around her neck, but she thought it must have been less than 5 minutes.

On 4/15/20, at 9:00 a.m. clinical nurse specialist (CNS)-S was interviewed and stated it was not hospital policy for staff to wait for security to intervene when a patient is harming him or herself. CNS-S stated when staff are trained, they are trained to wait for security if the patient has a weapon, a hostage, or is behind a barricade. CNS-S stated a patient under a desk is not considered to be behind a barricade. CNS-S stated staff should have assessed and intervened to ensure patient safety.

On 4/14/20, P1's physician (MD)-P was interviewed and stated that she was concerned as to why staff who were two staff to one patient, did not intervene when P1 was tying a ligature around her neck, and stop her from injuring herself. MD-P stated she had concerns that staff who have orders to maintain continuous observations of the patient did not consistently do so. MD-P stated P1 still had evidence of injury around her neck the next day.

The facility policy Levels of Observations reviewed 6/20, directed if a patient is on SIO for self-injury or suicide risk, they should be under continuous observation by staff at all times including when going to the bathroom and when in the shower.

The facility policy Restraint or Seclusion dated 6/17/20, directed the safety of the patient staff or others is the basis for initiating...the restraint...Restraint or seclusion for violent, self destructive behavior is used ...when there is a risk of a patient physically harming self.