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Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) patient records reviewed, the Hospital failed to ensure a timely Psychiatric Consultation was performed. Subsequently, Pt. #1 jumped from a window on the 10th floor Observation, Telemetry and Overflow Unit and died.

Findings include:

1. On 1/8/19, the Hospital's document titled, "Bylaws of the Medical Staff" (dated May 2016) was reviewed. The Bylaws required, "Consultations should be performed in a timely manner in keeping with the acuity and severity of the clinical condition. In general, it is expected that an initial consultation will be performed by the attending physician consultant within 24 hours of notification documented by a dated and signed consultation note."

2. On 1/7/19, Pt. #1's medical record was reviewed. Pt. #1 was a 47 year old male who was admitted to the Hospital's Observation, Telemetry, Overflow Unit on 12/23/18, after presenting to the Emergency Department on 12/22/18 with complaints of chest pain, shortness of breath and syncope (dizziness). Pt. #1 reported a history of anxiety and depression and requested Trazadone (anti-depressant medication) to help him sleep.

-Pt. #1's physician's order dated 12/24/18 at 1:33 PM, included, "psychiatric consult."

-Pt. #1's medical record lacked documentation of a psychiatric consultation.

-Pt. #1's nurse progress note dated 12/26/18 at 8:50 AM, included, "Called Psych [Psychiatry] to f/u [follow-up] with consult status for pt. [Pt. #1]. Asked if consult has been done since order was placed for 12/24/18 and there has been no notes written...Psych asked for order to be double checked as the order for the consult is not showing up on their system..."

3. On 1/8/19 at 8:28 AM, an interview was conducted with the Director of Quality (E #6). E #6 stated that the Root Cause Analysis showed that there was an error in the ordering process of the Psychiatric consultation and the consultation was not performed. E #6 stated that the psychiatry department did not receive the order because the consultation was requested for the wrong Physician.

Based on document review and interview, it was determined that the Hospital failed to ensure the safety of a patient (Pt. #1) while awaiting a psychiatric consultation. Pt. #1 subsequently jumped from the window of the 10th floor Observation, Telemetry, Overflow Unit and died.

Findings include:

1. The Hospital failed to ensure a patient (Pt. #1) was safe from harm. (A144-A)

2. The Hospital failed to fully investigate and identify all of the issues, after Pt. #1's death. (A144-B)

The Immediate Jeopardy (IJ) began on 12/24/18, when a psychiatry consultation was ordered for Pt. #1. No measures were put in place to ensure Pt #1's safety while awaiting the consultation. Subsequently, Pt. #1 jumped from a 10th Floor on the Observation, Telemetry, Overflow Unit and died. The Hospital failed to thoroughly investigate and identify all of the issues involving the incident. The Hospital failed to implement and evaluate corrective actions to prevent future occurrences, thus placing Medical and Surgical patients with mental health issues at serious risk for harm.

An Immediate Jeopardy (IJ) was identified and announced on 1/10/19 at 11:22 AM, during a meeting with the Hospital's Chief Medical Officer, Chief Operations Officer, Interim Vice President of Patient Care Services, President, and Director of Quality. The IJ was not removed be the survey exit date of 1/10/19.

Also, the Condition of Patient Rights, 42 CFR 482.13, was not met as evidenced by:

3. The Hospital failed to ensure that the Behavioral Health Unit was free from ligature risks. (A144-C)

4. The Hospital failed to ensure 1:1 (one staff to one patient) monitoring for a patient who presented to the Emergency Department with Suicidal ideation and a plan. (A144-D)

Based on document review, observation, and interview, it was determined that for 1 of 3 clinical records (Pt. #2), for patients on the 10th Floor Observation, Telemetry, Overflow Unit, the Hospital failed to ensure a Patient consented for Hospital treatment.

Findings include:

1. On 1/7/19 at 10:10 AM, the Hospital's policy titled, "Consent for Hospital Treatment," (revised February 2017), was reviewed. The policy included, "IV. A. Written Consent - This method of consent is authorized by means of the patient's signature (or person legally authorized to act on behalf of the patient) on the conditions for admissions and registration consent form... 3. The registrar will attempt to obtain consent from the patient's legal representative... 5. The registrar will document attempts... [when] authorization for consent for treatment is unobtainable..."

2. On 1/7/19 at 8:40 AM, an observational tour was conducted on the 10th Floor Observation, Telemetry, Overfow Unit. At 9:00 AM, Pt. #2 was in bed in room 1029 and a Certified Nursing Assistant was sitting in front of the open door performing close observations (visualization of the patient).

3. On 1/7/19 at 9:15 AM, Pt. #2's clinical record was reviewed. Pt. #2 was a 76 year old male, admitted on 1/3/19, with diagnoses of falls and altered mental status. Pt. #2's Consent for Treatment Form, dated 1/3/19, lacked Pt. #2's signature, legal representative's signature, or an explanation as to why a consenting signature was missing.

4. On 1/7/19 at 9:35 AM, an interview was conducted with the Nurse Manager of the 10th Floor Observation, Telemetry, Overflow Unit (E #2). E #2 stated that Pt. #2 fell and lost consciousness at a homeless shelter. Pt. #2 was placed on close observation for safety from falls. E #2 stated that no family for Pt. #2 was known, until a niece came to visit yesterday. The niece will take Pt. #2 home today when discharged. E #2 stated that someone from Administration should have signed for Pt. #2's consent when he was unable and had no family available.

A. Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) patient records reviewed, the Hospital failed to ensure the safety of a patient (Pt. #1) awaiting a psychiatric consultation. Subsequently Pt. #1 jumped from the 10th floor Observation, Telemetry, Overflow Unit and died.

Findings include:

1. On 1/7/19, the Hospital's policy titled, "Assessment and Reassessment of Patients" (dated 8/2017) was reviewed. The policy required, "...e. Nursing...6. Reassessments are done following significant changes or response to treatment. They are recorded in real time within Nursing Progress notes with a title of focus. Reassessments may be documented on [the] Focused Assessments Powerform. Frequency of assessment is based on patient need and unit standard. Nursing notes are encouraged to record the patient's response..."

2. On 1/7/19, Pt. #1's medical record was reviewed. Pt. #1 was a 47 year old male who was admitted to the Hospital's 10th floor (Observation, Telemetry and Overflow Unit), on 12/23/18 after presenting to the Emergency Department on 12/22/18 with complaints of chest pain, shortness of breath and syncope (dizziness). Pt. #1 reported a history of anxiety and depression and requested Trazadone (anti-depressant) to help him sleep.

-Pt. #1's discharge documentation dated 12/26/18 at 2:32 PM, included, " ...history of depression and was noncompliant, having recently been on three different medications of which he could not state dosages...Psychiatry had been consulted for assistance given his complicated history (suspect that he had more than depression and anxiety given he [Pt. #1] was also on lamictal [psychotropic medication]). We did not initiate antidepressants due to concern for adverse effects in the initial phase such as anxiety and increased suicidal ideation hence we did no feel comfortable without psych assistance...The patient denied suicidal ideation on the morning of 12/25 and 12/26 and tragically did commit suicide on 12/26...At 8:34 AM CODE BLUE (emergency cardiac/respiratory arrest) was called after the patient [Pt. #1] had committed suicide by jumping from his [Pt. #1] window the room ..."

-Pt. #1's nurse progress note dated 12/26/18 at 4:26 AM, included, "Pt. [Pt. #1] woke up from a nightmare and has been emotional sitting on the side of the bed. Pt. [Pt. #1] reported there is a lot on his mind and just wants to get his medications sorted out before he gets discharged. Spoke with MD (physician name) regarding pt. [Pt. #1] condition and his request for Benadryl. Pt. [Pt. #1] is at no risk for harming himself per RN assessment. MD wants to wait for AM team to arrive for f/u [follow-up] on his trazadone and other home medications. Pt. [Pt. #1] verbalized understanding. No new orders at this time. Will continue to monitor pt. [Pt. #1]."

-Pt. #1's nurse progress note dated 12/26/18 at 8:50 AM, included, "Called Psych [Psychiatry] to f/u with consult status for pt. [Pt. #1]. Asked if consult has been done since order was placed for 12/24/18 and there has been no notes written...Psych asked for order to be double checked as the order for the consult is not showing up on their system..."

-Pt. #1's Physician progress note dated 12/26/18 at 1:20 PM, included, " ...Overnight events ...Appears to be sad this morning. We had a lengthy conversation regarding what exactly is making him sad ...Denies any suicidal ideations ...Chronic conditions ...Called the crisis team again to see if the patient can be evaluated today. He [Pt. #1] is currently on disability for mental health issues. Awaiting Psychiatry recommendations ...Dispo (Disposition) Consulted Psychiatry for depression. Patient [Pt. #1] was on multiple medications for mood disorder. Awaiting psychiatry recommendations further evaluate the patient for depression and to recommend medication initiation..."

-Pt. #1's medical record did not include documentation of a suicide risk assessment by qualified personnel.

3. On 1/7/19 at 12:17 PM, an interview was conducted with a Certified Nursing Assistant/CNA (E #11). E #11 stated that she was assigned to care for Pt. #1 during the day shift on 12/26/18. E #11 stated that she received report from the night shift CNA that Pt. #1 seemed depressed overnight because he was pacing and requesting to speak to the Physician.

4. On 1/7/19 at 4:17 PM, an interview was conducted with a RN (E #10). E #10 stated that she took care of Pt. #1 on the night of 12/25/18 - 12/26/18. E #10 stated that Pt. #1 was pacing out of his room into the hallway throughout the night and requested Trazadone (anti-depressant medication). The on-call Physician was notified of Pt. #1's medication request but the on-call Physician did not order the Trazadone for Pt. #1 and stated that Psychiatry should evaluate Pt. #1 for recommendations. E #10 stated that at around 3:00 AM on 12/26/18, Pt. #1 awoke from a nightmare and was emotionally upset and crying. E #10 stated that she spent 15 - 20 minutes sitting with Pt. #1 while Pt. #1 voiced concerns over his divorce, unemployment, booted vehicle and homelessness. E #10 stated that she notified the on-call Physician of Pt. #1's emotional state. E #10 stated that the on-call Physician called back to the Hospital a 2nd time and asked if Pt. #1 was a harm to himself. E #10 stated that she did not feel that Pt. #1 was a harm to himself at the time. When asked if she (E #10) completed a suicide risk reassessment or increased monitoring for Pt. #1 after Pt. #1 appeared emotionally upset, E #10 replied, "No".

5. On 1/8/19 at 9:15 AM, an interview was conducted with a Certified Nursing Assistant (E #14). E #14 stated that she took care of Pt. #1 on 12/25/18 and he "seemed down". E #14 stated that Pt. #1 stated that he missed his daughter and wanted to be discharged but decided to stay another day to see the Psychiatrist.

6. On 1/8/19 at 12:56 PM, an interview with the Medical Director of the Behavioral Health Unit (MD #1) was conducted. MD #1 stated that a full psychiatric assessment of Pt. #1 was needed to determine if Pt. #1 was suicidal. MD #1 stated that Pt. #1 did not have a full psychiatric assessment by the psychiatry department.

B. Based on document review and interview, it was determined that the Hospital failed to conduct a thorough investigation to identify all of the issues related to Pt. #1's death, thus no safety interventions for patients with mental health issues on a medical unit (non behavioral health unit) have been implemented.

Findings include:

1. On 1/7/19, the Patient Safety Event Details/Root Cause Analysis dated 12/26/18 was reviewed. The Patient Safety Event Details/Root Cause Analysis included, "Order entered incorrectly. In the box for consulting MD [Medical Doctor], would enter the physician name whom is being requested to consult. What is entered in this box is the current attending. Resident reported to inconsistent exts [extension] when asked what line they called after putting in psych [psychiatric] consult. Resident [name] gave 2199 ...charge [nurse] repeated back the number to resident and let him know the nurses call a different number 2219. Order consultation was placed to [Physician name] ..."
-Pt. #1's Patient Safety Event Detail/Root Cause Analysis dated 12/26/18 was reviewed and lacked an investigation and identification of patient safety issues related to Pt. #1's death.

2. On 1/7/19, Pt. #1's medical record was reviewed. Pt. #1 was a 47 year old male who was admitted to the Hospital's 10th floor (Observation, Telemetry and Overflow Unit), on 12/23/18, after presenting to the Emergency Department on 12/22/18, with complaints of chest pain, shortness of breath and syncope (dizziness). Pt. #1 reported a history of anxiety and depression. and requested Trazadone (anti-depressant) to help him sleep.

3. On 1/8/19 at 8:28 AM, an interview was conducted with the Director of Quality (E #6). E #6 stated that the Root Cause Analysis dated 12/28/18, showed that there was an error in the ordering process of the Psychiatric consultation and the consultation was not performed. E #6 stated that the psychiatry department did not receive the order because the consultation was requested for the wrong Physician.


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C. Based on document review, observation, and interview, it was determined that for the East Psychiatric Unit, the Hospital failed to ensure that ligature risks were not present on the Psychiatric Unit. This could potentially affect future suicidal patients.

Findings include:

1. On 1/7/19 at 2:00 PM, the Hospital's policy regarding ligature risks was requested. On 1/7/19 at 3:45 PM, the Director of Quality and Patient Safety (E #6) stated the Hospital did not have a policy on ligature risks.

2. On 1/7/19 at 1:25 PM, an observational tour was conducted in the East Psychiatric Unit. The West Psychiatric Unit was closed at the time of the survey. There were 20 patients, none of whom were on suicidal risk observations. On the east side there were 14 solid wood doors with squared tops at the entrance to each patient room (rooms 402, 403, 404, 405, 406, 407, 408, 411, 412, 413, 414, 416, 417, & 418). The top of the doors and the upper door frames created a ligature risk (place where a cord, sheet, or other material could be secured and used for hanging).

3. On 1/7/19 at 1:30 PM, an interview was conducted with the Nurse Manager (E #5) of the Psychiatric Unit. E #5 stated that the patient room doors were not a ligature risk for the following reasons:

- There is always a staff member in the hall who could monitor all of the room doors.

- The Columbian suicide assessment risk is performed on admission and a mini suicide assessment risk is performed every 12 hours.

- There are safety rounds every 15 minutes.

- Staff will establish relationships with the patients so the patients will confide in the staff when feeling at risk.

- Suicidal patients are located closer to the nursing station.

E #5 stated that there is "no crystal ball" to determine when someone may attempt suicide. E #5 stated that the patient bathroom doors had been changed to half doors with no ligature risk and the patient room doors have a "continuous hinge" to prevent ligature risk from door hinges.

D. Based on document review, observation, and interview, it was determined that for 1 of 2 patients (Pt. #6), in the Emergency Department (ED) being treated for suicidal ideation, the Hospital failed to ensure that a patient presenting with suicidal ideation was monitored.

Findings include:

1. On 1/7/19 at 11:40 AM, the Hospital's policy titled, "Patient Sitter," (originated June 2018), was reviewed. The policy included, "V. Procedure: A. At Risk Behavior Clinical Indications for Sitter Use: 1. The following are indications for sitter use: Acute risk of suicide... C. Responsibility of Sitter While Sitting with Patient: 1. Provide continuous uninterrupted one-to-one direct observation of patient."

2. On 1/7/19 at 11:00 AM, an observational tour was conducted in the ED. At 11:10 AM, Pt. #6 was in bed in room 24 and a Registered Nurse (RN) (E #3) was sitting outside Room 24 facing the nursing station, not the patient. E #3 was instructed by the ED Director at 11:25 AM, to change positions, and to face the patient.

3. On 1/7/19 at 11:15 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a 52 year old male, who arrived in the ED on 1/7/19 at 8:22 AM, with diagnoses of suicidal ideation (SI) and hearing voices. Pt. #6's suicidal screening, dated 1/7/19, included, "Patient presents with depression and suicidal ideation with a plan to jump off the bridge". There was no order for one to one monitoring. There was no 15 minutes observation documentation.

4. On 1/7/19 at 11:10 AM, an interview was conducted with the RN (E #3) who was caring for Pt. #6. E #3 stated that Pt. #6 had just returned (at approximately 11:05 AM) from a CT Scan (computerized tomography) (series of X-ray measurements) completed due to Pt. #6 hearing voices. E #3 stated that Pt. #6 was on one to one observation and the one to one sitter "is sitting over there" nodding his head across the room toward room 16, where another SI patient was being monitored. E #3 stated that "we don't have the staff" for Pt. #6's 1 to 1 monitoring.

5. On 1/7/18 at 11:28 AM, the SI Patient in room 16 was admitted and the Sitter from room 16 came over to room 24 to monitor Pt. #6.