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I. Based on observation, document review, and staff interviews the acute care hospital's administrative staff failed to ensure psychiatric staff in 1 of 5 psychiatric units (7RCP) removed items from the patient environment, such as boxes of facial tissue and plastic silverware, that patients used in multiple and frequent attempts to self-harm and/or commit suicide. Failure to remove known items that patients attempted to engage in suicidal and self-harm behaviors resulted in the hospital's inability to provide a safe environment for these patients and could potentially result in serious injury or death if the item was used and the patient was not discovered in time. The psychiatric unit (7RCP) had a census of 25 patients upon entrance, 5 of the 25 patients on suicide and/or self-harm precautions. Please refer to A-0144.


II. During the investigation of of complaint 96961-C the on-sight survey team identified and Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient's Rights (42 CFR 482.13). The hospital staff failed to ensure the psychiatric staff kept the patient environment free of items patients used to engage in suicidal and/or self harm behavior.

While on site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 4/22/2021. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the hospital staff took the following actions:

a. the hospital staff placed identified patients 1:1 with direct observation indefinitely
b. the hospital staff relocated items from common areas to a secure location (including but not limited to): Tissue boxes and napkins, recreational materials: loose paper, magazines, newspapers, games, puzzles, crafts.
c. the hospital staff locked the dining room when not in use, staff member must be present when in use
d. the hospital staff ensured a staff person is present at the nurses' station at all time
e. the hospital staff educated all Behavioral Health Staff, float nursing staff, and on call nursing leadership on 4/22/2021 via a mass email. The hospital staff provided in person review of the information prior to the beginning a shift. Education included:
1. Risks identified in environment and subsequent removal of those items. Patients who need to use the items may ask for it at the nurses' station
2. Additional safe guards put in place including locking the dining room and ensuring the exercise room is locked when not in use
3. Constant staff presence at nurses' station
4. Specific safety precautions around the patients of concern
5. Sitters may not leave the patient's room without RN approval and break relief coverage
f. the hospital charge RN will ensure completion of frequent environmental round on the entire unit indefinitely. These hourly rounds will be documented. Any environmental concerns that cannot be immediately mitigated will be escalated to unit leadership.

Based on observation, document review, and staff interviews, the acute care hospital's administrative staff failed to ensure psychiatric staff maintained a safe environment, on 1 of 5 psychiatric units (7RCP), when they failed to remove and continued to make available environmental safety risk items (pens, paper products, plastic silverware) utilized by 2 of 5 patients (Patient #1 and Patient #3) identified as at risk for intentional harm to self and/or suicidal ideation. Failure to remove items patients previously demonstrated they used to engage in suicidal and/or self-harm behaviors created an opportunity for a patient to obtain objects intended to inflict self-harm or to facilitate an attempt to commit suicide, potentially resulting in serious injury or death if not discovered in time. The psychiatric administrative staff identified a total census of 25 patients on 7RCP; with 5 of 25 patients on suicide and/or self-harm precautions.

Findings include:

1. Review of the policy "Psychiatric Nursing Precaution/Observation - Adult Units," revised 9/2017, revealed in part, "Types of Psychiatric Nursing Precautions/Observations patients may be placed on include: ... Suicide Precautions ... Supervise the use of any potentially harmful items ... Conduct a room and/or unit search [as needed]." "Self-Harm Precautions ... Supervise the use of any potentially harmful items ... Conduct a room and/or unit search [as needed]."


2. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 on 10/29/20 to the hospital's inpatient behavioral health unit. The psychiatrist (a physician with specialized training in the treatment of patients with mental illness) ordered the nursing staff place Patient #1 on Suicide and Self-Harm precautions, after Patient #1 attempted to commit suicide prior to the hospital admission. The nursing notes in Patient #1's medical record indicated that Patient #1 had frequent thoughts of harming themselves, including by attempting to strangle themselves, including several attempts where Patient #1 attempted to use their hands to cut off their own airway or blood flow to the brain.

In addition, Patient #1 attempted to commit suicide multiple times while hospitalized on the inpatient behavioral health unit. Further review of Patient #1's medical record revealed:

a. On 12/25/20 at 1:46 AM, a nursing staff member was observing Patient #1 on 1:1 observation (a staff member was dedicated to observing Patient #1 at all times). Patient #1 attempted to commit suicide by stuffing paper towels into their nose and filling their mouth with paper towels. The nursing staff removed some of the paper towels from Patient #1's mouth, and Patient #1 coughed up the remaining paper towels in Patient #1's mouth/throat.

b. On 12/26/20 at 9:25 PM, while Patient #1 was on 1:1 observation, Patient #1 attempted to commit suicide by shoving paper towels down their throat and up their nose. The nursing staff removed the paper towels from Patient #1's mouth and nose.

c. On 1/2/21 at 6:15 PM, the nursing staff had removed Patient #1 from 1:1 observation. Psychiatrist K documented that Patient #1 attempted to commit suicide by stuffing toilet paper into their nose and mouth. The nursing staff returned Patient #1 to 1:1 observation.

d. On 3/22/21, the nursing staff documented that Patient #1 requested the nursing staff provide 1:1 observation for Patient #1, but Patient #1's treatment team (including Patient #1's psychiatrists and the nursing staff) determined Patient #1 should not have 1:1 observation, as Patient #1 wanted the increased staff attention from the 1:1 observation, which was not conducive to Patient #1's recovery.

e. On 3/24/21 at 10:16 PM, Patient #1 attempted to commit suicide by wrapping a blanket around their neck and stuffing their mouth and nose with tissue paper.

f. On 3/30/21 at 2:42 AM, Patient #1 attempted to commit suicide by wrapping a blanket around their neck and packing their mouth and nose with tissue paper.

g. On 3/31/21, the nursing staff documented in the Nursing Communication to lock Patient #1 out of their room during the day, to limit their access to items Patient #1 used to attempt to commit suicide.

h. On 4/3/21, during a pre-bedtime room search, the nursing staff found 2 tablets of 600 mg ibuprofen in Patient #1's room.

i. On 4/6/21 at 7:47 AM, the psychiatrist's daily progress note included documentation that Patient #1 stuffed tissue paper up their nose the night before.



3. Review of the hospital's incident reports revealed the following additional suicide attempts by Patient #1 that the nursing staff failed to document in Patient #1's medical record:

a. On 1/14/21 at 9:45 AM, the nursing staff completed an incident report indicating that they observed Patient #1 attempt to place medication in their hospital gown. The nursing staff searched Patient #1 and discovered 14 Tylenol tablets. Patient #1 admitted to nursing staff that Patient #1 intended to take the Tylenol tablets in an attempt to commit suicide.

b. On 4/15/21 at 11:45 PM, the nursing staff completed an incident report indicating that Patient #1 used paper towels to block their nose and mouth, tied a blanket around their neck while holding the blanket tight, and then used a chair to block Patient #1 under a desk.



4. Review of Patient #3's medical record revealed the nursing staff admitted Patient #3 to the hospital's inpatient psychiatric unit on 2/20/21 for suicidal ideations and eating disorder issues. Further review of Patient #3's medical record revealed:

a. On 3/12/21 at 10:01 PM, the nursing staff documented that Patient #3 had bruising on their neck from pulling on their necklace, visible swelling on their forehead, and Patient #3 reported they had bruising on their upper thighs from Patient #3 hitting themselves with a hair brush. Patient #3 engaged in the self-injurious behaviors to cope with their eating disorder.

b. On 3/20/21 at 9:41 PM, the nursing staff documented they found Patient #3 sitting on the floor of their bathroom, attempting to scratch themselves with a pen cap.

c. On 3/28/21 at 9:57 PM, the nursing staff documented that Patient #3 attempted to commit suicide by tying a sock around their neck.

d. On 4/5/21 at 9:04 PM, the nursing staff documented that Patient #3 gave the nursing staff Patient #3's toothpaste container to prevent Patient #3 from hurting themselves and a broken plastic cup.

e. On 4/8/21 at 7:20 PM, the nursing staff documented that Patient #3 used their toothpaste container to scratch themselves, resulting in 3 new scratches on Patient #3.

f. On 4/8/21 at 11:42 PM (approximately 4 hours after Patient #3's last attempt to harm themselves), the nursing staff documented they discovered Patient #3 attempting to scratch themselves in Patient #3's bathroom with a pen cap and plastic cup. Patient #3 reported they stole the pen cap and cup from the open nurses' station.

g. On 4/14/21 at 10:00 PM, the nursing staff documented that Patient #3 reported that Patient #3 had attempted to hurt themselves with a piece of plastic from their toothbrush wrapper. Patient #3 informed the nursing staff that they would not quit attempting to hurt themselves.

h. On 4/15/21 at 9:14 AM (approximately 11 hours after Patient #3's last attempt to hurt themselves), the nursing staff documented that Patient #3 reported they had attempted to hurt themselves all day, using items Patient #3 had accumulated from the inpatient psychiatric unit. Patient #3 indicated they used spoons, pen caps, and the toothpaste tube to harm themselves.

i. On 4/20/21 at 10:51 AM, the nursing staff documented that they observed Patient #3 attempting to scratch Patient #3's left heel with a pen cap.

j. On 4/21/21 at 4:28 PM, the nursing staff documented they found Patient #3 attempting to hurt themselves with a spoon.

k. On 4/21/21 at 7:49 PM (approximately 3 hours after Patient #3's last attempt to hurt themselves), the nursing staff documented that Patient #3 had 1:1 observation, but while on 1:1 observation, Patient #3 attempted to harm themselves with a spoon. Patient #3 pulled the spoon out of their pants and told the nursing staff that Patient #3 stole the spoon from their dinner tray.

l. 4/22/21 at 11:38 PM, the nursing staff documented that Patient #3 had 1:1 observation. While on 1:1 observation, Patient #3 was lying in bed and scratched their upper left thigh with a small pen.

m. On 4/24/21 at 10:49 AM, the nursing staff documented that Patient #3 had 1:1 observation. While on 1:1 observation, the nursing staff found a small spoon in Patient #3's bed after breakfast.

n. On 4/25/21 at 1:13 PM, the nursing staff documented that Patient #3 had 1:1 observation. While on 1:1 observation, Patient #3 gave the nursing staff a fork Patient #3 stole from their breakfast tray. Patient #3 reported they stole the fork when the staff members were not watching Patient #3.



5. During an interview on 4/26/21 at 3:05 PM, the Director of Behavioral Health Services acknowledged that Patient #3 obtained items used to harm themselves, but the nursing staff could not identify how Patient #3 obtained the items that Patient #3 utilized to harm themselves.

6. During an interview on 4/22/21 at 7:33 AM, Registered Nurse (RN) D revealed that Patient #1 attempted to commit suicide as a mechanism to cope with Patient #1's mental health problems. Patient #1 attempted to commit suicide by stuffing Patient #1's mouth and nose with paper towels and tissue paper. While Patient #1 was on 1:1 observation, the nursing staff limited Patient #1's access to toilet paper and paper towels.

7. During an interview on 4/21/21 at 2:00 PM, RN I revealed they allowed the patients to use the bathroom without a staff member constantly visualizing the patient unless the patient required 1:1 observation.

8. During an interview on 4/22/21 at 10:35 AM, Psychiatric Nursing Assistant (PNA) M revealed that, during a prior conversation with Patient #1, PNA M inquired where Patient #1 obtained the paper towels and tissue paper that Patient #1 used to stuff in their nose and mouth, in Patient #1's attempts to commit suicide. Patient #1 would not tell PNA M that Patient #1 did not obtain the paper towels and tissue paper from the bathroom, but Patient #1 would not provide any more specific details.

9. Observations on 4/22/21 at 10:00 AM revealed 4 boxes of facial tissue sitting on 4 tables in the psychiatric unit day room. Patient #1 was sitting at a table, working on a laptop. Further observations revealed a box of facial tissues sitting on the table where Patient #1 was working on the laptop. The nursing staff provided general observation of Patient #1, but did not dedicate a staff member to closely observing Patient #1, despite Patient #1's history of using paper towels and tissue paper to attempt to commit suicide.

10. During an interview on 4/22/21 at 10:05 AM, the Psychiatric Unit Nurse Manager indicated the nursing staff tried to balance the rights of all patients on the unit, and to maintain a therapeutic environment for all of the patients. The Psychiatric Unit Nurse Manager acknowledged the nursing staff did not remove the boxes of facial tissue from the patient care areas, despite Patient #1's repeated attempts to commit suicide by stuffing their mouth and nose with paper towels, tissue paper, and facial tissue.

Based on document review and staff interviews the acute care hospital administrative staff failed to ensure behavioral health staff followed the hospital's policies that required staff to complete an incident report regarding any incident that adversely affected or may adversely affect a patient for 3 of 3 patients (Patient #1, Patient #2, and Patient #3) records reviewed in 1 of 5 Behavioral Health Units (7RCP). Failure to file an incident report on events that adversely affected or may adversely affect a patient, such as a near miss, prevented the hospital quality and performance team from analyzing the incidents, which potentially resulted in the hospital staff failing to identify and implement measures to prevent the patients from obtaining items the patients later utilized in an attempt to harm themselves. The Behavioral Health Unit (7RCP) had a census of 25 patients upon entrance.

Findings include:

1. Review of the Administrative Policy "Comprehensive Incident Reporting and Peer Review", undated, revealed in part, "Incident: any unanticipated or unusual event, near miss [an event with the potential to harm a patient but did not harm the patient], ... pertaining to a patient ... Unsafe conditions are considered an incident." "Incident reports regarding patient care issues may be reviewed and followed up on by any one or more than one of the following ... [the appropriate] Hospital department ... Safety Oversight Team ..." "The [relevant groups] action plan shall identify the strategies the hospital intends to implement to reduce the risk of similar events occurring in the future." "Procedure for [completing a] safety incident ... After discovery of an incident, the staff member with the greatest knowledge of the incident shall submit an incident report ..."

2. Review of the "Performance Improvement Program FY 21," last revised 3/2021, revealed in part, "Objectives ... To collect data to monitor ... existing processes, identify opportunities for improvement, identify changes that will lead to improvement and sustain improvement ... To aggregate and analyze data on an ongoing basis and to identify changes that will lead to improved performance and in a reduction of errors." "UIHC performance opportunities are identified as follows: ... Patient Safety - Priorities for performance improvement activities are based upon: ... Identification of opportunities from incident reports ... Population characteristics: ... high risk [or] problem prone [areas] ..."

3. Review of "Riskonnect Safety Incident Reporting" training module, undated, revealed in part, "What is an Incident Reporting System? A Passive reporting system Allows to: Target system related issues, Explore patterns and trends, Reduce risk, Encourage a reporting and learning culture ... What is being reported? Incident (reached patient), Near Miss, Unsafe Condition." "Once an event is submitted: ... further review is initiated ... Investigation by Quality Improvement Program, department and unit, Safety Oversight Team, or Root Cause Analysis."


4. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 to the Behavioral Health Unit 7RCP on 10/19/20 by a psychiatrist. During Patient #1's hospitalization, the nursing staff documented approximately 14 incidents in Patient #1's medical record (from 11/26/20 to 4/22/21) that met the hospital's definition of an incident (which required the hospital staff to complete an incident report). The nursing staff completed an incident report on 4 of the approximately 14 documented events (incidents on 1/2/21, 1/14/21, 4/11/21, and 5/15/21). The staff completed incident reports when Patient #1 attempted to commit suicide by stuffing tissue paper and/or paper towels up their nose and into their mouth, and when Patient #1 wrapped items around their neck (including a blanket and electric bed cord).

Additional review of Patient #1's medical record revealed 10 additional incidents the nursing staff documented in Patient #1's medical record, but failed to create an incident report:

a. On 11/26/20 at 6:31 PM, the nursing staff documented that Patient #1 informed the nursing staff that Patient #1 drank soap from the bathroom soap dispenser.

b. On 11/27/20 at 11:45 PM, the nursing staff documented they found Patient #1 sitting in the shower, attempting to commit suicide, with a robe tied around their neck.

c. On 11/29/20 at 6:24 PM, the nursing staff documented they found Patient #1 attempting to commit suicide with a blanket tied around Patient #1's neck.

d. On 12/22/20 at 12:42 PM, the nursing staff documented that Patient #1 attempted to commit suicide by tying blankets around their neck.

e. On 12/25/21 at 1:46 AM, the nursing staff documented that Patient #1 attempted to commit suicide by filling their nose and mouth with paper towels.

f. On 12/26/21 at 9:25 PM, the nursing staff documented that Patient #1 attempted to commit suicide by shoving paper towels down Patient #1's throat and nose.

g. On 3/24/21 at 11:15 PM, the nursing staff documented that Patient #1 attempted to commit suicide by stuffing tissue paper and paper towels down Patient #1's mouth and up Patient #1's throat, and then Patient #1 wrapped a blanket around their neck.

h. On 3/30/21 at 2:42 AM, the nursing staff documented that Patient #1 attempted to commit suicide by stuffing tissue paper and paper towels down Patient #1's mouth and up Patient #1's throat, and then Patient #1 wrapped a blanket around their neck.

i. On 3/21/21 at 3:21 AM, the nursing staff documented that Patient #1 attempted to commit suicide by wrapping a blanket around their neck and barricading themselves under their desk.

j. On 4/6/21 at 7:47 AM, the nursing staff documented that Patient #1 attempted to commit suicide by stuffing tissue paper up their nose and Patient #1 wrapping their hair around their neck in an attempt to strangulate themselves.



5. Review of Patient #2's medical record revealed the hospital staff admitted Patient #2 to the Behavioral Health Unit 7RCP on 3/31/21 through 4/20/21. Review of Patient #2's medical record revealed 5 events which met the hospital's definition to require the staff to complete an incident report. The first event occurred on 4/11/21 at 12:51 PM, when the nursing staff found Patient #2 in their bathroom attempting to commit suicide by Patient #2 wrapping a cord around their neck.

Further review of Patient #2's medical record revealed 4 additional incidents that met the hospital's definition to require the nursing staff to complete an incident report, but the nursing staff failed to complete an incident report:

a. On 4/12/21 at 12:56 PM, the nursing staff documented that Patient #2 attempted to commit suicide when Patient #2 attempted to swallow a plastic bag while the nursing staff provided 1:1 observation of Patient #2.

b. On 4/15/21 at 1:45 PM, the nursing staff documented that Patient #2 handed the nursing staff paper towels and batteries that Patient #2 had hidden from the nursing staff. Patient #2 informed the nursing staff that Patient #2 intended to swallow the paper towels and batteries in an attempt to harm themselves.

c. On 4/15/21 at 1:22 PM, the nursing staff documented that Patient #2 handed the nursing staff a pen that Patient #2 fashioned into a weapon that Patient #2 considered using to harm themselves.

d. On 4/18/21 at 12:30 PM, the nursing staff documented that Patient #2 tied a pair of corded headphones around their neck in an attempt to commit suicide. The nursing staff documented that they needed to use a pair of safety scissors to remove the corded headphones from Patient #2's neck.



6. During an interview on 4/21/21 at approximately 9:30 AM, Nursing Practice Leader for Behavioral Health Services L acknowledged that the nursing staff failed to complete an incident report for the 4 incidents the nursing staff documented in Patient #2's medical record that met the hospital's definition to require the nursing staff to complete an incident report.


7. Review of Patient #3's medical record revealed that the hospital staff admitted Patient #3 to the Behavioral Health Unit 7RCP. The nursing staff documented that approximately 13 incidents in Patient #3's medical record, between 3/12/21 and 4/25/21, that met the hospital's definition that required the nursing staff to complete an incident report. The nursing staff completed an incident report on 2 of the events. The first event occurred on 3/28/21 at 9:57 PM, when Patient #3 tied a sock around their neck in an attempt to commit suicide. The second event occurred on 4/22/21 at 11:38 PM, when the nursing staff documented that Patient #3 used a small pen to scratch their left thigh.

Further review of Patient #3's medical record revealed 11 additional events which met the hospital's requirement for the nursing staff to complete an incident report, but the the nursing staff failed to complete an incident report:

a. On 3/12/21 at 10:01 PM, the nursing staff documented that Patient #3 had bruising on their neck from pulling on their necklace, visible swelling on their forehead, and Patient #3 reported they had bruising on their upper thighs from Patient #3 hitting themselves with a hair brush. Patient #3 engaged in the self-injurious behaviors to cope with their eating disorder.

b. On 3/20/21 at 9:41 PM, the nursing staff documented they found Patient #3 sitting on the floor of their bathroom, attempting to scratch themselves with a pen cap.

c. On 4/5/21 at 9:04 PM, the nursing staff documented that Patient #3 gave the nursing staff Patient #3's toothpaste container to prevent Patient #3 from hurting themselves and a broken plastic cup.

d. On 4/8/21 at 7:20 PM, the nursing staff documented that Patient #3 used their toothpaste container to scratch themselves, resulting in 3 new scratches on Patient #3.

e. On 4/8/21 at 11:42 PM (approximately 4 hours after Patient #3's last attempt to harm themselves), the nursing staff documented they discovered Patient #3 attempting to scratch themselves in Patient #3's bathroom with a pen cap and plastic cup. Patient #3 reported they stole the pen cap and cup from the open nurses' station.

f. On 4/14/21 at 10:00 PM, the nursing staff documented that Patient #3 reported that Patient #3 had attempted to hurt themselves with a piece of plastic from their toothbrush wrapper. Patient #3 informed the nursing staff that they would not quit attempting to hurt themselves.

g. On 4/15/21 at 9:14 AM (approximately 11 hours after Patient #3's last attempt to hurt themselves), the nursing staff documented that Patient #3 reported they had attempted to hurt themselves all day, using items Patient #3 had accumulated from the inpatient psychiatric unit. Patient #3 indicated they used spoons, pen caps, and the toothpaste tube to harm themselves.

h. On 4/20/21 at 10:51 AM, the nursing staff documented that they observed Patient #3 attempting to scratch Patient #3's left heel with a pen cap.

i. On 4/21/21 at 4:28 PM, the nursing staff documented they found Patient #3 attempting to hurt themselves with a spoon.

j. On 4/21/21 at 7:49 PM (approximately 3 hours after Patient #3's last attempt to hurt themselves), the nursing staff documented that Patient #3 had 1:1 observation, but while on 1:1 observation, Patient #3 attempted to harm themselves with a spoon. Patient #3 pulled the spoon out of their pants and told the nursing staff that Patient #3 stole the spoon from their dinner tray.

k. On 4/24/21 at 10:49 AM, the nursing staff documented that Patient #3 had 1:1 observation. While on 1:1 observation, the nursing staff found a small spoon in Patient #3's bed after breakfast.

l. On 4/25/21 at 1:13 PM, the nursing staff documented that Patient #3 had 1:1 observation. While on 1:1 observation, Patient #3 gave the nursing staff a fork Patient #3 stole from their breakfast tray. Patient #3 reported they stole the fork when the staff members were not watching Patient #3.


8. During an interview on 4/22/21 at 10:35 AM, Psychiatric Nursing Assistance (PNA) M revealed they received training on how to complete an incident report in their new hire orientation. However, PNA M further revealed that the PNAs normally pass along any information which required the staff to complete an incident report to the patient's assigned RN, and the patient's assigned RN would complete the incident report.

9. During an interview on 4/22/21 at 9:05 AM, PNA G revealed they recently became aware that the PNAs should complete the incident report if the PNA witnessed the event. PNA G further revealed that normally a RN completed an incident report, using the information that the PNA provided to the RN.

10. During an interview on 4/22/21 at 7:33 AM, Registered Nurse (RN) D revealed that the patient's assigned nurse should complete complete an incident report for any unusual event, including patients attempting suicide.

11. During an interview on 4/22/21 at 10:10 AM, RN H revealed they did not understand the specifics on the hospital's incident reporting policy. RN H would only complete an incident report if a patient or staff member suffered an injury, as the hospital staff tracked the injury incident reports.

12. During an interview on 4/21/21 at 1:57 PM, RN I revealed the nursing staff needed to complete an incident report only on incidents which the nursing staff could prevent, but RN I then acknowledged they did not complete an incident report if they encountered a "near miss" situation.

13. During an interview on 4/21/2021 at 2:30 PM, RN J revealed they work with the quality improvement program and trained hospital staff on the use of the of the Incident Reporting System. RN J reported that the nursing staff should complete an incident report for any incident that actually reached a patient, with or without resulting harm, a near miss, or any unsafe condition. The hospital staff examine all incident reports critically and address any incident reports with a high impact on patient safety during the daily safety brief huddles. The hospital leadership, nurse managers, medical directors, and staff all the way up to the CEO, get involved in the daily safety brief huddles. RN J acknowledged that the nursing staff should have completed an incident reports for the incidents identified in Patient #1's medical record.

14. During an interview on 4/27/21 at 8:00 AM, the Nurse Manager of 7RCP and the Director of Behavioral Health Services acknowledged the individual with the most knowledge of the incident should have completed an incident report on any unanticipated or unusual event, near miss, or any unsafe condition. The Nurse Manager of 7RCP and the Director of Behavioral Health Services also acknowledged that the nursing staff's failure to complete the incident reports hindered the hospital staff's ability to measure, assess, and take action to improve the performance of the clinical staff and improve the patient care, including potentially identifying trends in patients attempting to commit suicide and identifying methods to prevent the patients from obtaining items the patients could use to hurt themselves.