HospitalInspections.org

Based on record review, the hospital failed to provide an environment free of mechanisms for self injury for 1 of 1 patients identified with suicidal ideation in a sample size of 20.

Findings include:
Review of the care plan for patient #1 created on 11/3/15 at 10:43 p.m. revealed the patient was identified at risk for suicide and the hospital would ensure the patient's safety by providing a therapeutic environment and appropriate interventions. This care plan remained in effect through discharge on 11/8/15.

Review of the Activities in the Clinical Documentation Record revealed action items to provide a safe environment under the Suicide Safe Environment Checklist. Review of the nurses notes dated 11/6/15 at 12:50 a.m. revealed the checklist was not completed and items were left in the patient's room that the nurse had identified as instruments for self injurious behavior. These items were used on 11/8/15 at approximately 1:45 a.m. by patient #1 to attempt suicide.