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I. Based on observation, interviews and record review, the facility failed to ensure that 1 of 2 active patients added to the sample for medical review (S5) was provided with adequate medical and nursing care. Patient S5 was observed in the facility lethargic, and unresponsive. Review of the record and interviews revealed the patient was unable to provide for his/her own nutritional and fluid needs, and these were not adequately noted on the treatment plan nor provided for by the facility, ultimately leading to the necessity, during the survey, that the patient be transferred elsewhere for rehydration and medical care. Patient S5 required transfer to an urgent care center, where staff was unable to start intravenous fluids secondary venous collapse from dehydration. The patient was then transferred to a community hospital for stabilization. The facility's failure to adequately identify and provide treatment for medical problems and/or assure timely transfer to a medical facility increased Patient S5's morbidity and placed the patient at risk for further harm. These failures led to an IMMEDIATE JEOPARDY status, initiated on 11/4/11 at 1:00p.m. (Refer to B118 regarding the treatment planning failures and B125 for treatment failures.)


The facility was informed of the IMMEDIATE JEOPARDY status in a conference with the Chief Executive Officer and Director of Quality Improvement on 11/4/11 at 1:00p.m. The Medical Director and Director of Nursing were not available at that time.

Based on record review and interviews, the facility failed to ensure that active medical problems were included on the Master Treatment Plan (MTP) of 1 of 2 non-sample patients (S5) added to the sample for review of medical problems. Patient S5 was admitted to the facility on 10/29/11 with a history of chronic renal failure, hematuria and agitated delirium. The patient was not able to eat or drink without assistance. Internal medicine physician progress notes dated 10/31/11 identified the medical problems and the physician wrote nursing orders for intervention. However, these problems were not included in the Master Treatment Plan. Failure to include active medical problems on Patient S5's treatment plan potentially contributed to the facility's failure to adequately address these problems, increasing patient morbidity and need for transfer to a general medical hospital on 11/03/11 for hydration, nutrition and cardiac stabilization.

Findings include:

A. Record Review

1. Patient S5 was admitted to the facility on 10/29/11, A Psychiatric Evaluation dated 10/30/11 for Patient S5 included diagnoses of "Probable Delirium" and Medical Diagnoses of "History of Renal Failure; urinary retention; atrial fibrillation (A fib); coronary artery disease; chronic obstructive pulmonary disease (COPD); hypoxemia (low blood oxygen)."

2. The Master Treatment Plan dated 10/30/ did not mention the patient's delirium. Although the plan listed the medical diagnoses of "Hypertension, COPD, BPH (benign prostatic hypertrophy), A fib (Atrial Fibrillation), and Chronic renal insufficiency," none of those medical diagnoses were included on the "Master Problem List." The only listed problem was "DTO (danger to others), out of contact with reality." The listed long term goal was "will have adequate sleep and po (oral) intake." There were no short term goals or interventions for the patient's need for "po intake."

3. The facility's Policy and Procedure titled "Treatment Planning-Interdisciplinary", dated 08/07 and revised 10/09, noted that "treatment plan updates are to be completed twice a week." According to this policy, Patient S5 should have had an updated treatment plan during the first week of hospitalization (between 11/2/11 and 11/4/11). As noted above, there was no treatment plan update in the record as of 11/4/11 at 12p.m.

B. Interviews

1. In an interview on 11/3/11 at 9a.m., when asked if medical problems are routinely included in the Master Treatment Plan, MD1 stated, "No, I'm not involved in writing the treatment plan."

2. In an interview on 11/3/11 at 10:30a.m., when asked about Patient S5's lack of po intake (fluids and food), RN2 agreed that these problems should have been on the Master Treatment Plan.

3. In an interview on 11/3/11 at 11:30a.m., the Medical Director agreed that medical problems for patients should be part of the Master Treatment Plan. The Medical Director also acknowledged that Patient S5's lack of oral intake should have been a separate problem on the MTP.

4. In an interview on 11/4/11 at 8:45a.m., MD3 (attending psychiatrist for Patient S5) stated, "If it (intake) is a problem, we should have transferred [S5] out to a hospital and not treat [S5] here."

Based on observation, interviews and record review, the facility failed to ensure that 1 of 2 active patients added to the sample for medical review (S5) was provided with adequate medical and nursing care. Patient S5 was admitted as a transfer from a community hospital on 10/29/11 with a provisional diagnosis of delirium and agitated behavior, and multiple medical problems. On 11/2/11 at 9:30a.m., Patient S5 was observed tilted back in a reclining chair with both eyes closed and with crusty exudates on the eyelashes bilaterally. Patient S5 was seated in the day room area, not responding to the program that was in progress. Record review revealed that there were physician orders to "push fluids" and provide nutritional supplements, but observations revealed nursing staff were not assisting Patient S5 with hydration or meals. The attending psychiatrist failed to coordinate medical care for Patient S5 by not responding in a timely way to recommendations by the internal medicine consultant. This delayed Patient S5's transfer to a general medical facility. Patient S5 was initially transferred to an urgent care center, where the staff was unable to start intravenous fluids secondary venous collapse from dehydration. Patient S5 was then transferred to a community hospital for stabilization. The facility's failure to provide treatment for medical problems and/or assure timely transfer to a medical facility increased Patient S5's morbidity and placed the patient at risk for further harm.

Findings include:

A. Observations

1. During an observation on 11/2/11 at 9:30a.m., Patient S5 was seen sitting in a recliner in the back of the day room during an exercise/stretching group. Patient S5 was not responding to the music or group instructions. Patient S5's eyes were closed with dried excretions around the upper and lower eyelashes. A urine catheter bag was attached to chair; the urine collected in the bag was red colored indicating possible hematuria (blood in the urine).

2. An observation in the patient dining room on 11/2/11 at 12 p.m. revealed Patient S5 seated at the dining table in a recliner. Patient S5's lunch was in front of him/her on the table and had not been touched. Patient S5 was lethargic and not responding to the milieu. Observation throughout the lunch period revealed no nursing staff assisting Patient S5 with eating or drinking. The patient's tray remained untouched until it was picked up at 12:40p.m.

3. The only time Patient S5 was observed to be responsive on the afternoon of 11/2/11 was during visiting hours at 3p.m. when the patient attempted to reach out to hold his/her spouse's hand a couple of times. Throughout the afternoon, Patient S5 sat in the chair not responding to his/her surroundings, even as staff wheeled him/her into and out of group activities.

4. During an observation in the patient dining room on 11/3/11 at 8:30a.m., Patient S5 was sitting in a recliner chair with a breakfast tray in front of him/her on the table. The meal remained untouched, Nursing staff did not attempt to help Patient S5 eat or drink during the observation. Patient S5 was not responsive to the surroundings. Patient S5's eyes were closed with excretions noticeable on the eyelids.

B. Interviews

1. In an interview on 11/2/11 at 10:30a.m., MD1 stated that Patient S5 was not getting hydration and appeared to not be responding to hospital treatment. MD1 stated that Patient S5 needed to be transferred to hospice care or a community hospital, depending on what the family preferred. When asked about physician orders for "pushing fluids" and giving "nutritional supplements" not being carried out by nursing staff, MD1 stated, "I'm not surprised."

2. In an interview on 11/2/11 at 11a.m., RN2 was asked about the physician orders for Patient S5. RN2 could not explain why a physician order written on 10/31/11 for twice a day nutritional supplements had not yet been initiated.

3. In an interview on 11/2/11 at 2:30p.m., RN2 was again asked about the ordered nutritional supplements for Patient S5. [[Nursing staff had not given the supplement at lunch time as ordered]. RN2 was also shown Patient S5's Daily Intake and Output Record (DIOR) for 10/31/11 and 11/1/11 which showed that the average amount of fluids the patient received each day was around 1000 cc. The Initial Nutrition Assessment Screen for Patient S5, dated 10/30/11, also was reviewed. The nutritionist suggested that Patient S5 receive twice a day nutritional supplements and that S5 receive about 2200 cc per day of fluids. When asked about the difference between nursing giving 1000 cc per day versus the recommended 2200 cc per day, and the physician orders for the nutritional supplement and pushing fluids, RN2 stated, "I guess the nurses aren't doing their job of either following the doctor's order or documenting."

4. In an interview on 11/2/11 at 12:20p.m. MHT1 stated that Patient S5 had not eaten since coming in and that staff didn't have a doctor's order to feed the patient.

5. In an interview on 11/3/11 at 11:30a.m. the Medical Director acknowledged that nursing staff should be providing assistance with meals for patients who are unable to eat or drink on their own. The Medical Director could not explain why the physician orders for Patient S5's nutritional supplements were not initiated by nursing staff.

6. In an interview on 11/4/11 at 8:30a.m., MD1 stated that Patient S5 had been sent to the community hospital following transfer to the urgent care center because an IV could not be started secondary to collapsed veins and dehydration.

7. In an interview on 11/4/11 at 8:45a.m., MD4, the attending psychiatrist for Patient S5, stated, "I don't do much with medical issues especially for this patient because [S5] is delirious and there isn't much a psychiatrist can do for delirium. I leave it for the [internist] to manage." When asked if s/he was aware that Patient S5 was not eating or drinking for the prior 2 days of hospitalization, MD4 stated, "no." MD4 added, "If a patient is too medically ill, we just transfer them out. [S5] should have been transferred sooner." When it was noted that the internist had written a progress note on 11/2/11 that recommended the patient's transfer, and MD4 was queried about whether he had seen the progress note or discussed the medical status with the internist, MD4 responded "No; the internist should have just taken care of it. I'm not involved in the medical care of the patients."

C. Record/Document Review

1. A Psychiatric Evaluation by MD4 dated 10/30/11 stated that Patient S5 was diagnosed with "Probable psychosis, not otherwise specified; Probable Delirium; Dementia, possibly of Alzheimer's type with behavioral problem." The listed Medical Diagnoses included "History of Renal Failure; urinary retention; atrial fibrillation (A fib); coronary artery disease; chronic obstructive pulmonary disease (COPD); hypoxemia (low blood oxygen)."

2. The Master Treatment Plan for Patient S5 dated 10/30/11 failed to list the medical problems and appropriate interventions. Refer to B118 for details.

3. In an Initial Nutritional Assessment dated 10/30/11 at 12p.m., the following was recommended for Patient S5: a "heart healthy mechanical soft diet with Ensure Plus twice a day. Maintain good po intake to greater than 75% at meals consumed." Nutritional requirements for fluids were estimated to be 2190 cc per day.

4. A written order by a physician's assistant dated 10/31/11 at 7:20p.m. stated, "Encourage oral fluids 500 ml po tid (three times a day) for 5 days."

5. An order written by MD1 on 10/31/11 (untimed) and signed off by nursing on 11/1/11 stated the following, "Please do weekly weights; Give Ensure Plus supplements 1 can po bid (twice a day)...Keep a record of intake (fluids and food)."

6. The Daily Intake and Output Record (DIOR) for 10/30/11 noted 1140 cc total fluid intake; no meals were noted. The DIOR for 10/31/11 noted 1860 cc fluid intake, with 960 cc of water being given during the evening shift. No meals were noted on the DIOR for 10/31/11. The DIOR for 11/1/11 noted 1080 cc of fluid for the day, no meals were noted. There was no DIOR for 11/2/11 in the patient's record.

7. Nursing notes written every shift between 10/30/11 and 11/3/11 did not address Patient S5's difficulty with hydration or nutrition. The nursing notes did document that the patient was confused and did not respond to "med teaching." There was no evidence that nursing staff had assisted the patient with meals or with hydration.

8. The Medication Administration Record (MAR) noted that the Ensure Plus that was ordered on 10/31/11 was first to be given on 11/2/11. According to the MAR, on 11/2/11 at 3:00pm, the Ensure had not been given at 7a.m. or 12p.m. The MAR also had an empty box drawn in for a weight to be determined on 11/2/11; there was no evidence that the patient had been weighed that day.

9. There were no additional nursing notes that explained why the ordered Ensure had not been given prior to 11/2/11 at 3p.m. or why the patient's weight had not been determined on 11/2/11.

10. A Progress Note by MD1, dated 11/2/11 at 8:30a.m., noted under the section for "Plan": "increase po intake; discuss with [MD4] pt being transferred to inpatient hospice for continued care and management vs (versus) hospital for IV hydration. S/S (social service) working on plan."

11. A Psychiatric Progress Note dated 11/2/11 at 11:44a.m. did not mention anything about transferring the patient out of the facility. The note stated, "The patient's oral intake is poor."

12. There were no social service notes written on 11/2/11.

13. A Progress Note by MD1, dated 11/3/11 at 8:50a.m., stated, "Patient minimally responsive, Pt is lethargic. Pt's po intake has been almost none, urinary output is poor...Discussed case with attending physician and nurses....Plan: IV fluid hydration; S/S working on discharge/transfer planning to inpatient hospice; will monitor and follow up."

14. An order by MD1, dated 11/3/11 at 9:00a.m., stated, "Please transfer patient to urgent care for IV fluid hydration." The order was taken off by the charge nurse on 11/3/11 at 11:45a.m.

15. A Psychiatric Progress Note by MD4 (patient's attending psychiatrist), dated 11/3/11 at 11:50a.m., stated, "The patient is alert, oriented to person only, indifferent on approach and marginally cooperative....Blood pressure 161/104 (elevated); pulse 105 (elevated); respirations 16 (normal). The patient remains withdrawn, requires total nursing care. [S5's] oral intake has been minimal. The patient's insight is absent and [S5's] overall judgment remains impaired. No major behavior problems observed. Plan: Consider hospice care." There was no mention of the medical issues discussed by MD1 and no discussion of Patient S5 being transferred that morning for IV hydration.

16. A telephone order by MD4 on 11/3/11 at 2p.m. noted "Pt being transferred to [community hospital] for abd (abdominal) mass. Discharge pt."

Based on record review and interviews, the facility failed to adequately evaluate suicide risk in order to protect patients from self harm for one patient who completed suicide two days after discharge from the facility (Patient X1). Specifically:

I. The Medical Director failed to ensure that psychiatrists documented suicide risk assessments on admission and discharge, addressed concerns about the status of patient X1 during hospitalization, and assured that recommendations for follow-up care of patient X1 were in place (refer to B144 for these findings.)

II. The Director of Nursing failed to assure nursing participation in treatment planning during hospitalization of patient X1, to ensure communication of concerns about the patient, who committed suicide after discharge (refer to B148 for these findings.)

III. The Director of Social Services failed to ensure that social work staff documented suicide assessments during hospitalization and upon discharge, and completed necessary referrals for patient X1 (refer to B152 for these findings.)

IV. Additionally, the facility failed to initiate corrective measures in a timely manner to ensure that current inpatients, including 8 of 8 active sample patients (E1, E2, E3, E4, S1, S2, S3 and S4), had documented suicide risk assessments. Failure to provide a comprehensive suicide assessment places all patients at risk for suicide.

The lack of adequate evaluation of suicide risk and plan for follow-up, as well as the failure of the facility to immediately review the circumstances of the suicide led to a status of IMMEDIATE JEOPARDY being initiated on 11/4/11 at 1:00pm. The facility was informed of the IMMEDIATE JEOPARDY status on 11/4/11 at 1:00pm.

Based on record review and interviews, the Medical Director failed to ensure that the medical staff completed and documented suicide risk assessments at admission and on the day of discharge for all patients. The Director failed to assure that concerns regarding patient X1's status during hospitalization were addressed, and that recommendations for follow-up care were in place at the time of signing for discharge for patient X. Patient X1completed a suicide two days after discharge. Review of the death record revealed that required suicide risk assessments had not been completed, that progress notes did not address the patient's status, and follow-up appointments had not been secured. In addition, although the death was identified as a sentinel event by the facility, the Medical Director, who was informed of the death on 10/29/11, as of 11/04/11 had not initiated and documented an investigation into the death of Patient X1. The Medical Director also failed to protect current inpatients by failing to ensure that medical staff documented suicide risk assessments. None of the eight active sample patients (E1, E2, E3, E4, S1, S2, S3 and S4) had suicide risk assessments.

Findings include:

A. Record Review

1. During a review of death records, it was noted that Patient X1 had died from a self inflicted gunshot wound on 10/29/11, two days after discharge from the facility. Review of the Psychiatric Evaluation for the patient, dated 10/24/11, showed that Patient X1 was a 78 year old person who was admitted to the facility on 10/23/11 after intentionally overdosing with twenty Percocet tablets. At the time of admission, Patient X1 had been experiencing depression related to family and financial problems; s/he had no previous psychiatric history. The admitting diagnosis was noted as Major Depressive Disorder, single episode without psychosis. Problems were noted as: "1. Recent suicide attempt, 2. Major depression with SI (Suicidal intent) and related symptoms, 3. Anxiety stressors and lack of coping skills." No suicide risk assessment was present.

2. A Clinical Evaluator's Intake Assessment dated 10/23/11 at 12:30p.m. stated the following under the section for "Presenting Problems": "Pt alternately denies SI and then states 'He took 20 of Percocet so that he would start feeling better, saying he would end it all so that he does not have to face his problems on a day-to-day basis [sic].'"

3. An Admission Nursing Assessment for Patient X1, dated 10/23/11 at 10:31p.m., noted the following under the section "Suicide Risk Factors:" "Potential for self harm": (checked "yes"); "Recent History of Attempt": (checked "yes"); "Is patient being admitted post suicide attempt, from Acute Care Hospital?" (checked "yes"); "Does patient have access to gun/dangerous weapon/lethal medications?" (checked "no"); "Is patient unable to contract for safety?" (checked "yes.")

4. A History and Physical Examination dated 10/23/11 at 11p.m. noted the following statement in the section titled "History of Present Illness": "Denies suicidal ideation but states 'I took the Percocet so that I would start feeling better and end it all so that I do not have to face my problems again on a day to day basis.'" Under the section, "Factors Needing Immediate Attention," the following was noted: "Safety/ fall risk/ADLs (activities of daily living)/Suicidal tendencies." No suicide risk assessment was present.

5. In a nursing progress note dated 10/25/11 at 2p.m., the RN stated, "Patient makes silly remarks about the depression medication 'depressing' him more."

6. In a nursing progress note dated 10/26/11 at 1:10a.m., the RN stated, "Pt isolative and withdrawn, non-social with peers...sits quietly in milieu watching TV, remains quiet and withdrawn."

7. A social worker note, written on 10/25/11 stated, "the family asked for the pt. to remain in the hospital as long as possible."

8. A Psychiatric Progress Note dated 10/25/11 at 11a.m. noted the following under the section "Mental Status": "Suicidal: Ideas? ("No" box checked); Intent? (neither the "Yes" box nor the "No" box was checked); Plan? (neither the "Yes" box nor the "No" box was checked)." Under the section for "Plan," the progress note stated, "Will need fu (follow up) appt (appointment) with Psych provider/therapist" and "needs monitoring with new antidepressant tx (treatment) and OP (outpatient) tx plan/safety plan before discharge."

9. In the Master Treatment Plan dated 10/26/11, Patient X1's problem was noted as "danger to self as evidenced by intentional overdose, increased anxiety, increased stress." The anticipated date of discharge was noted as 11/6/11. The long term goal was "pt will not harm self; mood and bx (behaviors) stabilized prior to d/c (discharge)." Short term Goals were "Pt will display no episodes of verbal or physical gestures or statements of self harm for three consecutive days." The target date was 11/6/11 (same as anticipated discharge date). The attending psychiatrist, social worker and activity therapist signed the "Team Members Participating in the Formulation the Master Treatment Plan [sic)] section; there was no nursing signature present. The patient was discharged on 10/27/11.

10. A Psychiatric Progress Note dated 10/26/11 (untimed) noted the following under the section "Mental Status": "Suicidal: Ideas? ("No" box checked); Intent? (neither the "Yes" box nor the "No" box was checked); Plan? (neither the "Yes" box nor the "No" box was checked)." Under the section "Plan," the progress note said "estimated D/C (discharge) date: tomorrow or Friday 10/28/11 and psych follow up tomorrow or Friday 10/28."

11. There was no psychiatric progress note in the medical record for 10/27/11.

12. There was no social work progress note on either 10/26/11 or 10/27/11.

13. The Physician Discharge Order, dated 10/27/11 at 10:30 a.m., noted the following under the section "Risk": "[box checked] Patient evaluated and determined not to be an imminent danger to self or others." There was no explanation on the form as to how the evaluation was performed or the conclusion was drawn. The order page was signed by the attending psychiatrist.

14. The Discharge Aftercare Plan dated 10/27/11 at 10:30-11 a.m. noted the follow up appointment as: [Primary Care Physician] 11/1/11 at 9:10a.m.; [Local counseling center] "will contact pt to set up assessment." There was no psychiatric follow up appointment documented in the Discharge Aftercare Plan, despite the fact that the psychiatric progress note dated 10/26/11 (see above) suggested a psychiatric follow up appointment shortly after discharge. The note was signed by a nurse and social worker on 10/26/11 and by the patient on 10/27/11. Because the patient signed a day after the clinical staff, it was not clear whether or not the plan had been reviewed with the patient.

15. On 11/4/11, the surveyor reviewed all 8 active sample patients' medical records (E1, E2, E3, E4, S1, S2, S3 and S4). None of the records contained a formal admission suicide risk assessment.

B. Interviews

1. In an interview on 11/2/11 at 11:30a.m., the care of Patient X1 was discussed with MD4 (attending psychiatrist). The discussion included a review of a social worker note, written on 10/25/11 which stated, "the family asked for the pt. to remain in the hospital as long as possible." MD4 stated, "[Patient X1] was a voluntary patient and if [X1] wanted to leave, we had no reason to keep [the patient] here." MD4 was asked whether there was any documentation in the patient record of a suicide risk assessment being performed by a physician on the day of discharge; MD4 stated "no."

2. In an interview on 11/2/11 at 1p.m., the Director of Quality Improvement (QI Director) stated that the death of Patient X1 was going to be treated as a sentinel event and that a root-cause analysis was going to be performed. When asked whether the root cause analysis had been started yet, the QI Director stated "no, but we're planning on getting to it."

3. In an interview on 11/3/11 at 11:30a.m., the Medical Director acknowledged that physicians do not document a suicide risk assessment in the record either on admission although the form has a space fot his, or upon discharge, although this was required by the check off on the order sheet at discharge. She also acknowledged that physicians do not write progress notes on the day of discharge. She stated, "The discharge summary serves as the progress note for the last day of hospitalization." When asked if the discharge summary is in the patient's record on the day of discharge, the Medical Director stated, "Doctors have two weeks to get the discharge summary in the chart. I guess we should have some kind of suicide assessment in the chart on the day of discharge to prove it was done."

4. In an interview on 11/4/11 at 1:30p.m., with the Chief Executive Officer (CEO) and the Director of Quality Improvement, the CEO stated, "We have started to investigate the case (X1) but we were going to meet yesterday and didn't. It takes a while for us to get everyone together." When asked if there is a time frame for initiating a sentinel event review, both the CEO and the Director of Quality Improvement stated "no." When asked about the immediacy of possible danger to other patients if there isn't a suicide risk assessment for current patients in the hospital, the CEO stated "This was our first suicide; we're still gathering data."

Based on observation, interview and record review, the Director of Nursing failed to ensure that nursing staff was actively involved in the treatment planning process. For one patient (X1) whose record was reviewed for death after discharge, nursing staff did not attend the treatment team meetings. Without nursing presence at treatment planning, concerns about Patient X1's status identified in progress notes may not have been communicated. This information would have been valuable for the team in determining treatment for the patient's depression. The lack of nursing representation at treatment planning meetings hampers the interdisciplinary team's ability to assess the patient's response to treatment, utilizing all available information.

Findings include:

A. Record Review

1. In a Psychiatric Evaluation dated 10/24/11, Patient X1 was a identified as a 78 year old person who had been admitted to the facility on 10/23/11 after intentionally overdosing with twenty Percocet tablets. Patient X1 had been experiencing depression secondary to family and financial problems and had no previous psychiatric history. Admitting diagnosis was noted as Major Depressive Disorder, single episode without psychosis. Problems were noted as "1. Recent suicide attempt, 2. Major depression with SI (Suicidal intent) and related symptoms, 3. Anxiety stressors and lack of coping skills."

2. Admission Nursing Assessment dated 10/23/11 at 10:31 pm noted under the section "Suicide Risk Factors" the following: "Potential for self harm: (checked) yes", "Recent History of Attempt: (checked) yes", "Is patient being admitted post suicide attempt, from Acute Care Hospital?, (checked) yes", "Does patient have access to gun/dangerous weapon/lethal medications? (checked) no", "Is patient unable to contract for safety? (checked) yes."

3. Clinical Evaluator's Intake Assessment dated 10/23/11 at 12:30pm noted the following quote under the section for Presenting Problems: "Pt alternately denies SI and then states 'He took 20 of Percocet so that he would start feeling better, saying he would end it all so that he does not have to face his problems on a day-to-day basis[sic].'"

4. In a nursing progress note dated 10/25/11 at 2:00pm, the RN noted "Patient makes silly remarks about the depression medication 'depressing' him more."

5. In a nursing progress note dated 10/26/11 at 1:10am, the RN noted "pt isolative and withdrawn, non-social with peers...sits quietly in milieu watching TV, remains quiet and withdrawn."

6. In the Master Treatment Plan dated 10/26/11, Patient X1's problem was noted as "danger to self as evidenced by intentional overdose, increased anxiety, increased stress." Anticipated date of discharge was noted 11/6/11. Long term goal was noted as "pt will not harm self; mood and bx (behaviors) stabilized prior to d/c (discharge)." Short term Goals included "Pt will display no episodes of verbal or physical gestures or statements of self harm for three consecutive days." Target date was 11/6/11. The attending psychiatrist, social worker and activity therapist signed the "Team Members Participating in the Formulation the Master Treatment Plan (sic)" section; there was no nursing signature present.

7. In a nursing progress note dated 10/27/11 at 11:30am, the RN noted "Pt was DC'd (discharged) at 1100 with family. Pt left in a stable condition, denies SI (suicidal intent), all belongings returned." There was no description of how a suicide assessment was completed by the RN to determine the lack of suicidal intent.

B. Interview

In an interview on 11/2/11 at 3:30pm, the Director of Nursing acknowledged that nursing staff should be involved in providing risk assessments for all patents.

Based on record review and interviews, the Director of Social Services failed to ensure that social work staff documented patients' suicide risk on admission and discharge, and docuemtned follow-through on recommended discharge plans. Patient X1 was discharged on 10/27/11 and committed suicide on 10/29/11. There were no social work progress notes documenting the patient's risk for suicide. Additionally, the attending psychiatrist had requested that Patient X1 have an outpatient appointment with a mental health provider immediately after discharge. The social work discharge instruction form (Discharge Aftercare Plan) did not include an appointment with a psychiatrist or therapist. Instead, it noted that a clinic would be contacting the patient for follow-up. There were no social work progress notes in the patient's record that explained the discrepancy. Failure of social work staff to assess patients for suicidality and ensure that patients have specific and timely mental health follow- up plans when discharged potentially places patients at risk for unsuccessful transfer from inpatient to outpatient care.

Findings include:

A. Record Review

1. During a review of death records, it was noted that Patient X1 had died from a self inflicted gunshot wound on 10/29/11, two days after discharge from the facility. According to the Psychiatric Evaluation dated 10/24/11, Patient X1 was an elderly person admitted to the facility on 10/23/11 after intentionally overdosing with twenty Percocet tablets. Patient X1 had been experiencing depression secondary to family and financial problems and had no previous psychiatric history.

2. The Admission Nursing Assessment dated 10/23/11 at 10:31p.m. noted the following under the section "Suicide Risk Factors:" "Potential for self harm": (checked "yes"); "Recent History of Attempt": (checked "yes"); "Is patient being admitted post suicide attempt, from Acute Care Hospital?" (checked "yes"); "Does patient have access to gun/dangerous weapon/lethal medications?" (checked "no"); "Is patient unable to contract for safety?" (checked "yes")

3. Patient X1's History and Physical Examination, dated 10/23/11 at 11p.m., noted the following statement in the section titled "History of Present Illness": "Denies suicidal ideation but states 'I took the Percocet so that I would start feeling better and end it all so that I do not have to face my problems again on a day to day basis'." Under the section "Factors Needing Immediate Attention" the following was noted: "Safety/fall risk/ADLs (activities of daily living)/Suicidal tendencies."

4. A Clinical Evaluator's Intake Assessment dated 10/23/11 at 12:30p.m. noted the following under the section "Presenting Problems": "Pt alternately denies SI and then states 'He took 20 of Percocet so that he would start feeling better, saying he would end it all so that he does not have to face his problems on a day-to-day basis [sic].'"

5. In the Master Treatment Plan dated 10/26/11, Patient X1's problem was noted as "danger to self as evidenced by intentional overdose, increased anxiety, increased stress." Anticipated date of discharge was noted 11/6/11. Long term goal was noted as "pt will not harm self; mood and bx (behaviors) stabilized prior to d/c (discharge)." Short term Goals included " Pt will display no episodes of verbal or physical gestures or statements of self harm for three consecutive days." Target date was 11/6/11. The attending psychiatrist, social worker and activity therapist signed the "Team Members Participating in the Formulation the Master Treatment Plan (sic)" section. Patient was discharged 10/27/11.

6. Psychiatric Progress Note dated 10/25/11 at 11:00am noted under the section for "Mental Status" the following: "Suicidal: Ideas? (Checked No box), Intent? (Neither the Yes box or No box was checked), Plan? (Neither the Yes box or No box was checked). Under the section for "Plan": "Will need fu (follow up) appt with Psych provider/therapist." Also noted was a statement stating "needs monitoring with new antidepressant tx (treatment) and OP (outpatient) tx plan/safety plan before discharge."

7. Psychiatric Progress Note dated 10/26/11 (untimed) noted under the section for "Mental Status" the following: "Suicidal: Ideas? (Checked No box), Intent? (Neither the Yes box or No box was checked), Plan? (Neither the Yes box or No box was checked). Under the section for "Plan": "estimated D/C date: tomorrow or Friday 10/28/11 and psych follow up tomorrow or Friday 10/28."

8. There was no social work progress note on either 10/26/11 or 10/27/11.

9. The patient's Discharge Aftercare Plan dated 10/27/11 at 10:30-11:00a.m. noted the following follow up appointments: [Primary Care Physician] 11/1/11 at 9:10a.m.; [Local counseling center] "will contact pt to set up assessment." There was no psychiatric follow up appointment in the note, although the psychiatric progress note dated 10/26/11 suggested a follow up appointment shortly after discharge. The plan was signed by a nurse and social worker on 10/26/11 and by the patient on 10/27/11.

10. On 11/4/11, all active sample patients' medical records were reviewed (E1, E2, E3, E4, S1, S2, S3 and S4). None of the records contained a formal admission suicide risk assessment.

B. Interview

In an interview on 11/3/11 at 2:30p.m., the Director of Social Services confirmed that there social work should do suicide risk assessments, and there were no social service notes in the record that included a suicide assessment. She also acknowledged that there were no social service notes in Patient X1's medical record for the last two days of hospitalization, other than to acknowledge that a psychosocial evaluation had been completed and that there had been a family contact.