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Based on document review, observation and interview, it was determined that the Hospital failed to ensure care was provided in a safe setting by ensuring that the suicide risk assessments were conducted. This potentially places any patient requiring suicide risk assessments on the Medical-Surgical Unit at risk for serious harm or death. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure the suicide risk assessment was done every shift for a patient admitted with suicidal ideation, as required for safety. See deficiency at A - 0144 A.

An Immediate Jeopardy (IJ) began on 06/24/2021 due to Hospital's failure to conduct the necessary assessment on a patient with suicidal ideation. Subsequently, a patient death by suicide followed.

An Immediate Jeopardy was identified on 07/02/2021, at 42 CFR 482.13, Patient Rights, and was announced on 07/02/20121 at 3:45 PM, during a meeting with the President/CEO, Chief Nursing Officer, Vice-President of Operations, Director of Speciality Services, Chief Medical Officer, Vice-President of Patient Safety, REgional Director for Accreditation Services, Risk Manager, Risk Manager, Patient Safety Specialist and Regional Director of Quality. The Immediate Jeopardy was not removed by the survey exit date of 07/02/2021.

A. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed for patients with suicidal ideation on the medical-surgical unit, the Hospital failed to conduct a suicide risk assessment, as required, to ensure care was provided in a safe setting. This could potentially affect all patients admitted to the medical surgical unit requiring suicide assessments to prevent injury or harm.

Finidngs include:

1. The Hospital's policy titled, "Initial Suicide Screening and Assessment Process (ED and Non-Behavioral Health Inpatients" (revised 3/21/2020) was reviewed on 07/01/2021 and required, " ... B. The overall level of risk for suicide and the plan to mitigate the risk for suicide is documented in the patient's medical record ... CSSRS means Columbia Suicide Severity Rating Scale. Suicide ideation means thought of suicide ... C. Protocol ... 10. Patients who screen positive on admission will be screened on every shift until transferred to another level of care or discharged ..."

2. On 7/2/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital by paramedics on 6/9/2021 with primary impression of (drug) overdose. The clinical record included:

- MD #1's (Psychiatrist) psychiatric evaluation note, dated 6/16/202,1 included, "(Pt. #1) ... with chief complaint: Suicide attempt via overdose. I wanted to die ... (Pt. #1) reports depression that has occurred since her husband passed away 3 years ago, but it has significantly worsened since the pandemic. (Pt. #1) has periods of tearfulness, significant suicidal ideation including preparatory behaviors for the past several weeks, including writing over 65 letters to family and friends, taking a picture of the plot she wishes to be buried in, and planning who would take care of her cat. She feels guilt, helplessness, hopelessness, significant fatigue, decreased ability to concentrate and make plans ... She reports feeling she is a burden to her family, and was hopeful that her death would help them financially ... Principal problem: Suicide ideation ... Plan ... Special precautions: 1:1 for suicidality ..."

- The clinical record indicated that Pt. #1 was on 1:1 monitoring from 6/10/2021 through 6/20/2021 for safety/suicide risk. The 1:1 monitoring was discontinued by MD #1 on 6/20/2021. Pt. #1 was on 1:1 monitoring for fall risk from 6/20/2021 through 6/21/2021. The clinical record indicated that Pt. #1 was on hourly rounding from 6/21/2021 through 6/29/2021.

- On 6/25/2021, at 7:48 PM, E #7's (Registered Nurse) progress note indicated, "At (2:00 PM) noted clumps of (Pt. #1's) hair on ground of patient's room. Upon further investigation a small pair of scissors were found on patient's bathroom counter ... Writer also noted a Ziploc bag next to her suitcase with brown capsules inside, (Pt. #1) stated they are her vitamins from home. Writer examined (Pt. #1's) belongings ... noted multiple Ziploc bags with different colored pills/capsules in them ... with patient's permission and noted multiple Ziploc bags with different colored pills/capsules in them. Writer confiscated scissors as well as all home (medications) noted in the room ... Home (medications) placed in patient specific bin in (medication) room ... Scissors handed off to charge RN ... (Pt. #1) denies cutting herself, stated, 'No, I only trimmed my hair. My family member brought it.' (MD #1) made aware (with) no new orders. (MD #2) updated with new orders to place a visitors restriction for all visitors to this patient. No visitors allowed at this time due to safety. Security notified. Front lobby notified. Charge RN aware."

- The clinical record indicated that the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment was not completed from 6/24/2021 (night shift) through 6/29/2021, prior to patient's death.

- The nursing progress notes from 6/26/2021 at 12:43 AM, 6/26/2021 at 4:16 PM, 6/27/2021 at 1:26 AM, 6/27/2021 at 4:11 PM, and 6/28/2021 at 4:08 AM included either suicidal behavior or depression as Pt. #1's ongoing problem.

- E #7's (Registered Nurse) progress note, dated 6/29/2021 at 7:50 PM, included, " ...This RN noticed the patient in the bathroom, hanging by the neck, via gait belt that was secured to the shower curtain rod. The patient was hanging freely with no objects underneath ... Patient noted with no movement. No respirations noted. Lips noted blue, extremities mottled... (At 2:45 PM) ICU resident was able to get into contact patient's sister ... and notify of current situation. (At 2:53 PM) (Name of physician) pronounced this patient deceased ..."

- The physician's progress note, dated 6/29/2021 at 3:13 PM, indicated that Pt. #1 was pronounced dead on 6/9/2021 at 2:53 PM.

3. On 7/1/2021 at approximately 2:30 PM, an interview was conducted with MD #1 (Psychiatrist). MD #1 stated that he would expect for nurses to conduct suicide risk assessments. MD #1 said, "It is important because she had suicidal ideation to monitor her behavior. Based on this case, she (Pt. #1) still needed suicide risk assessments. Hard to say, but I think it would have been good to ask."

4. On 7/2/2021 at approximately 9:40 AM, an interview was conducted with E #2 (Medical Surgical Manager). E #2 stated that based on MD #1's psychiatric evaluation, Pt. #1 scored positive on the CSSR (Columbia Suicide Severity Rating Scale). E #2 stated that the CSSR screening should have been completed every shift.

5. On 7/2/2021 at approximately 10:15 AM, an interview was conducted with E #7 (Registered Nurse/RN on Medical Surgical Unit) regarding the episode on 6/25/2021. E #7 stated that it was (06/25/2021 episode) concerning to her because of Pt. #1's history of suicide attempt. However, E #7 stated that it was not necessary to do the suicide risk assessment. E #7 stated that she did not know the protocol regarding the suicide risk assessment and nobody has talked her.

6. On 7/2/2021 at approximately 10:45 AM, a telephone interview was conducted with another Medical Surgical Unit RN (E #10) who took care of Pt. #1. E #10 stated that nobody talked to her about every shift suicide risk reassessments.

7. On 7/2/2021 at approximately 11:00 AM, an interview was conducted with E #1 (Chief Nursing Officer. E #1 stated that the Hospital's current suicide risk assessment policy is confusing.




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B. Based on document review and interview, it was determined that, for 1 of 2 clinical records ( Pt. #3) reviewed at Hospital location A, the Hospital failed to ensure care was provided in a safe setting by maintaining safety interventions for patients requiring Constant Observation (1:1). This has the potential to affect any patients requiring observation on census as of 07/01/2021.

Findings include:

1. The Hospital's policy titled,"Patient Safety Attendant (PSA) and Remote Companions" was reviewed on 07/01/2021 at approximately 1:00 PM, and included, "II. Key Principles-A. All staff who cares for patients at risk for suicide will be trained and competent to care for the suicidal patients...III...A. Constant Observation (1:1) means One to One (1:1) observing the patient 24 hours a day, in immediate proximity with continuous visual observation to immediately intervene."

2. Pt. #3 was admitted on 06/29/2021 with diagnosis of Suicidal Ideation's. The clinical record included a physician's order, dated 06/29/2021, for 1:1 observation.

3. The Constant Observation Monitoring Logs for Pt. #3 for 06/30/2021 at 5:00 PM through 07/01/2021 at 11:00 AM were reviewed on 07/01/2021 and included, "Location Code, behavior code and fall prevention measure are to be documented every 15 minutes". The clinical record lacked documentation of Pt #3's location, behavior, and fall prevention measures every 15 minutes from 9:00 PM - 9:30 PM (30 minutes).

4. The findings were discussed with Nurse Manager (E #2). E #2 stated that there was no documentation in the clinical record to indicate why the every 15 minute check was not completed.