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Based on document review, video review, observation and interview it was determined, that for 1 of 1 (Pt. #1) patient on suicide precautions resulting in death, 2 of 2 Psychiatric units (4 East and 3 East), and 1 of 3 (Pt. #2) clinical records reviewed for 1:1 (one patient-to-one staff member) monitoring, the Hospital failed to ensure that Psychiatric patients were safe from ligature risks and environmental hazards. This potentially affects all current and future Behavioral Unit Patients. As a result, the Condition of Participation (42 CFR 482.13) Patient Rights was not in compliance. The Immediate Jeopardy was not removed by the survey exit date of 3/1/18.

Findings Include:

1. The Hospital failed to ensure observational rounds were performed every 15 minutes as required. (A144-A).

2. The Hospital failed to ensure patient rooms were free from ligature risks and environmental hazards to prevent harm to patients. (A144-B)

3. The Hospital failed to ensure the patient was monitored, as required. (A144-C)

The immediate jeopardy began on 2/23/18 with Pt. #1 committing suicide by hanging on the 4 East nursing unit. Pt. #1 was not monitored every 15 minutes as required.

An Immediate Jeopardy was identified on 2/28/18 for the Hospital's failure to conduct an environmental assessment and evaluate ligature risks, thus placing all psychiatric patients at serious potential risk for harm.

An Immediate Jeopardy was announced on 2/28/18 at 8:50 AM, during a meeting with the Chief Operating Officer, Chief Executive Officer, Chief Medical Officer and Chief Nursing Officer. The Immediate Jeopardy was not removed by the survey exit date of 3/1/18.

A. Based on document review, video review and interview, it was determined that for 1 of 1 (Pt. #1) patient on suicide precautions resulting in a death, the Hospital failed to ensure observation rounds were performed every 15 minutes as required.

Findings include:

1. The Hospital policy titled, "Monitoring of Patients on High Risk Precaution (2/17)" was reviewed on 2/27/18. The policy required, "Patients on ... CO (close observation) ... are automatically placed on every 15 minute observation".

2. The clinical record of Pt. #1 was reviewed on 2/27/18. Pt. #1 was a 33 year old female admitted on 2/18/18 with the diagnoses of depression and suicidal thoughts. A physician's order dated 2/18/18 at 3:34 PM included, "Close observation throughout admission." The High Risk Precautions Monitoring form dated 2/23/18 included documentation of every 15 minute rounds from 12:00 AM to 4:45 AM.

3. On 2/27/18 at 1:00 PM, a video recording of the hallway on 4 east on 2/23/18 from 12:00 AM - 6:00 AM was reviewed . The videotape footage shows that no staff member entered Pt#1's room from 2:25 AM until 5:23 AM (178 minutes).

4. During an interview on 2/27/18 at approximately 11:30 AM, the Chief Nursing Officer (E#1) stated, "I reviewed the video and (Pt. #1) was not checked on by our staff for about 3 hours, even though it was documented that she was checked on."

B. Based on observation and interview, it was determined for 2 of 2 Psychiatric Units (4 East - 10 rooms and 3 East - 12 rooms), the Hospital failed to ensure patient rooms were free from ligature risks and environmental hazards to prevent serious harm to patients. This could potentially affect the 19 patients currently on census.

Findings include:

1. An observational tour of the 3 East psychiatric unit on was conducted on 2/27/18 at 9:45 AM. Each room contained a wheeled bedside table, that could be rolled around the room. There were 12 unlocked bathroom doors in occupied patient rooms. The unlocked bathroom doors were flat/square at the top with a L- shaped (lever style)door handle.

A tour of 4 East was conducted on 2/27/18 at approximately 10:30 AM. Each room contained two platform beds and a bedside table on wheels.

2. During an interview on 2/27/18 at approximately 11:30 AM, the Chief Nursing Officer (E#1) stated, "Pt#1 placed a sheet over the door and used the bedside table to jump from to commit suicide by hanging herself. We need to figure out something else to use for personal items that cannot be used by a patient to hurt themselves."


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C. Based on document review, observation, and interview, it was determined that for 1 of 3 (Pt. #2) clinical records reviewed for 1:1 (one patient-to-one staff member) monitoring, the Hospital failed to ensure the patient was monitored, as required.

Findings include:

1. The Hospital policy entitled, "Monitoring of Patients on High Risk Precaution," (revised: 02/17) required, "Policy...The highest level is 1:1. Patients on 1:1 are to be within arms length of the staff member assigned to monitor them ...any patient assessed to be at high risk for violence, self-injury...be placed on High Risk Precaution."

2. On 2/27/18 at approximately 9:45 AM an observational tour was conducted on the 3 East Behavioral Health Unit. During the tour, the patient in room East 312 (Pt #2) was identified as on 1:1 monitoring. The sitter (E #4) assigned to the patient was in the hall talking with a co-worker. During an interview, E #4 stated, "I just stepped out to get a breath of fresh air."

3. The clinical record of Pt #2 was reviewed on 2/27/18 at approximately 10:30 AM. Pt #2 was a 65 year old female admitted on 2/21/18 with a diagnosis if bipolar disorder. Pt #2's clinical record contained a physician's order dated 2/21/18 that required, "1:1 Sitter." Pt #2's High Risk Precautions Monitoring sheets dated 2/24/18 and 2/25/18 failed to indicate that Pt #2 was monitored on 1:1 precautions (as required).

4. The Chief Nursing Officer (E #1) was interviewed on 2/27/18 at approximately 1:00 PM. E #1 stated the observation sheets should have included all of the precautions. E #1 stated that the Survey and Certification Memo: 18-06-Hospitals, dated December 8, 2017, required, "1:1 monitoring with continuous visual observation" and she thought that was all she needed to follow.