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Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was a documented care plan, as required by Hospital policy, for three out of ten medical records reviewed.

Findings include:

Background information:
The Hospital reported that Patient #1 attempted to commit suicide on 10/9/11 at 10:30 am by hanging a bedsheet over the bathroom door. Patient #1 was unresponsive and required bag and mask ventilation. Patient #1 was transported to the Medical Intensive Care Unit for further treatment and evaluation and was discharged and transferred to an inpatient psychiatric facility on 10/11/11. This was the second suicide attempt at the Hospital. The first attempt occurred 6/22/11, when Patient #1 was staying on a medical unit and was found hanging in the shower with a sheet around his/her neck. A CMS authorized survey was conducted in response to the incident. Documentation indicated and RN #1 said that Patient #1 denied suicidal ideation on the day of the incident and had agreed to rest in his/her room until a scheduled 10:30 AM x-ray. A 10:15 safety check found Patient resting in bed. At 10:30 A.M. Patient #1 was found hanging in the bathroom with a sheet draped over the bathroom door and tied around the neck.

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The Nurse Manager (Manager) was interviewed in person on 10/27/11 at 8:50 am with the Risk Manager present at her request. The Manager said the nursing care plan was documented on the initial assessment and on the Interdisciplinary Treatment Plan.

The Hospital policy that addressed the interdisciplinary treatment plan was reviewed. Review of the policy regarding treatment planning and monitoring indicated that: Based on the data gathered during the assessment process and the resulting assessment of the patient's needs, the team will formulate a treatment plan. The treatment plan will identify specific short-term and long-term goals and the clinical modalities, other interventions, settings and services necessary to accomplish them. a) Each patient shall have a written individualized treatment plan based on an assessment of the patient's needs and strengths.

A. Review of Patient #1's clinical record indicated that although a nursing care plan was completed during the Patient #1's initial assessments, documentation did not indicate the nursing care plan was incorporated into a treatment plan and addressed Patient #1 safety needs.

Documentation did not indicate a written individualized treatment plan was completed at any time during Patient #1's ten day psychiatric unit admission.

B. Review of Patient # 2's clinical record did not indicate that a written individualized treatment plan was completed at any time during Patient #2's fifteen day psychiatric unit admission.

C. Review of Patient # 7's clinical record did not indicate that a written individualized treatment plan was completed at any time during Patient #7's four day psychiatric unit admission.