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Based on clinical record reviews, review of hospital policies and documentation, and interviews, the hospital failed to provide care in a safe setting when a patient with suicidal ideation was not provided the appropriate level of supervision providing an opprotunity for the patient to harm self, resulting in a finding of Immediate Jeopardy.


Please see A144

Based on clinical record reviews, review of hospital policies and documentation, and interviews with staff for 1 of 10 patients with suicidal ideation (Patient #1), the hospital failed to provide care in a safe setting when staff failed to provide the appropriate level of supervision, providing an opportunity for the patient to harm self, resulting in a finding of Immediate Jeopardy. The findings include:


1. Patient #1 was admitted to a medical unit in the hospital on 7/15/16 for medical treatment following an intentional overdose of prescription medications. A physician's history and physical dated 7/15/16 identified that Patient #1 wanted to commit suicide and would do so by hanging self or by taking an overdose of his/her medications. A physician order dated 7/15/16 directed "suicide precautions" with a sitter "1:1" (arms length).

On 7/16/16 at 7:00 AM and again at 3:00 PM, the electronic sitter log maintained by Clinical Nurse Managers incorrectly identified Patient #1's reason for a sitter as "alcohol detox" and not suicide precautions as ordered. Subsequently, a patient care technician (PCT) #1 was assigned as a sitter for Patient #1 and the patient's roommate on 7/16/16 at 3:00 PM. Interview with PCT #1 on 8/2/16 at 10:00 AM identified that on 7/16/16 at 3:00 PM he/she was told by off-going PCT #2 that Patient #1 "took drugs" and was on 1:1. PCT #1 identified that he/she did not receive instructions from a nurse and believed that both Patient #1 and the roommate were on constant observation.

On 7/16/16 at approximately 4:30 PM, Patient #1 was pending medical discharge with subsequent admission for in-patient psychiatric treatment and requested to take a shower prior to discharge. RN #1 was with Patient #1's roommate during this timeframe and provided Patient #1 with towels for the shower. Patient #1 was left unsupervised in the bathroom with the door closed. At approximately 4:35 PM, RN #1 knocked on the bathroom door, did not get a response, and upon opening the door found Patient #1 with a bathroom shower fixture (hand held shower hose) around the neck. The patient was unresponsive and pulseless with agonal breathing.

Patient #1 was successfully resuscitated, transferred to the ICU, intubated, placed on hypothermia protocol due to concern for anoxic brain injury, and treated for laryngeal edema. Following Patient #1's recovery, he/she was discharged to an in-patient psychiatric hospital on 7/22/16 with no lasting medical problems.

Review of the hospital policy for "sitter/safety companions for patient safety" identified that the staff member providing 1:1 observation must remain within arms length to the patient. The rationale for 1:1 observation includes "actively suicidal/homicidal".

Interviews with PCT #1 on 8/2/16 at 10:00 AM and PCT #2 on 8/1/16 at 11:30 AM indicated they had completed observation flowsheets for Patient #1, however, the clinical record failed to include a 1:1 constant observation flowsheet per policy, which is used for identifying a patient's safety observation status and documenting that monitoring was provided. In addition, there was no other documentation in the clinical record of the 1:1 observation monitoring.

Interview with the Director of Patient Safety and Regulatory on 7/29/16 at approximately 3:00 PM identified that there were no 1:1 constant observation flowsheets for Patient #1 for 7/15/16 or 7/16/16.

Interview with RN #1 on 8/1/16 at 2:00 PM identified that on 7/16/16 it was reported to her that Patient #1 was suicidal, admitted due to a drug overdose and that Patient #1's observation status was to be 1:1. RN #1 identified that he/she was aware that there was only one sitter available to observe Patient #1 and the roommate. RN #1 identified that he/she was in Patient #1's room with PCT #1 at the time of the incident.




2. Interview with PCT #3 on 7/29/16 at 2:10 PM identified that he/she was assigned and acting as a sitter to Patient #2 for 1:1 observation at the time of interview. Upon surveyor inquiry regarding the difference between constant observation and 1:1 observations, PCT #3 stated that he/she didn't think there was a difference because both required full vision all the time. PCT #3 did not identify that 1:1 observations required the sitter to be within arms length of the patient.




3. Based on review of the clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 10 of 10 patients (Patients #1-#10) admitted to the hospital requiring suicide precautions and on 1:1 observation (arm's length), documentation and interviews failed to reflect that the 1:1 observations were implemented. The findings include:

Review of the clinical records for Patients #1-#10 and review of the hospital ' s Sitter Observation Log identified that each patient was admitted with suicide precautions and 1:1 observation. Although Observation Flowsheets were completed for part and/or all of the patients' hospitalization as per policy, the Flowsheets failed to differentiate between 1:1 and constant observation. Review of the Safety Observation Policy indicated that 1:1 observation was within arm's length for suicide precautions. Whereas, for constant observation, the patient was to be within view of the sitter. Review of the clinical records failed to reflect 1:1 observation (arm's length) was implemented.
Interviews with the Chief Nursing Officer and the Director of Patient Safety on 8/2/16 at 2:00 PM failed to identify that the 1:1 observations were implemented for Patients #1-#10.

Based on clinical record reviews, review of hospital policies and documentation, and interviews, nursing staff failed to provided the appropriate level of supervision for a patient with suicidal ideation, providing an opprotunity for the patient to harm self, resulting in Condition level non-compliance.


Please see A395

Based on clinical record reviews, review of hospital policies and documentation, and interviews with staff for 1 of 10 patients with suicidal ideation (Patient #1), nursing staff failed to provided the appropriate level of supervision for a patient with suicidal ideation, providing an opprotunity for the patient to harm self. The findings include:


1. Patient #1 was admitted to a medical unit in the hospital on 7/15/16 for medical treatment following an intentional overdose of prescription medications. A physician's history and physical dated 7/15/16 identified that Patient #1 wanted to commit suicide and would do so by hanging self or by taking an overdose of his/her medications. A physician order dated 7/15/16 directed "suicide precautions" with a sitter "1:1 (arms length).

On 7/16/16 at 7:00 AM and again at 3:00 PM, the electronic sitter log maintained by Clinical Nurse Managers incorrectly identified Patient #1's reason for a sitter as "alcohol detox" and not suicide precautions as ordered. Subsequently, a patient care technician (PCT) #1 was assigned as a sitter for Patient #1 and the patient's roommate on 7/16/16 at 3:00 PM. Interview with PCT #1 on 8/2/16 at 10:00 AM identified that on 7/16/16 at 3:00 PM he/she was told by off-going PCT #2 that Patient #1 "took drugs" and was on 1:1. PCT #1 identified that he/she did not receive instructions from a nurse and believed that both Patient #1 and the roommate were on constant observation.

On 7/16/16 at approximately 4:30 PM, Patient #1 was pending medical discharge with subsequent admission for in-patient psychiatric treatment and requested to take a shower prior to discharge. RN #1 was with Patient #1's roommate during this timeframe and provided Patient #1 with towels for the shower. Patient #1 was left unsupervised in the bathroom with the door closed. At approximately 4:35 PM, RN #1 knocked on the bathroom door, did not get a response, and upon opening the door found Patient #1 with a bathroom shower fixture (hand held shower hose) around the neck. The patient was unresponsive and pulseless with agonal breathing.

Patient #1 was successfully resuscitated, transferred to the ICU, intubated, placed on hypothermia protocol due to concern for anoxic brain injury, and treated for laryngeal edema. Following Patient #1's recovery, he/she was discharged to an in-patient psychiatric hospital on 7/22/16 with no lasting medical problems.

Review of the hospital policy for "sitter/safety companions for patient safety" identified that the staff member providing 1:1 observation must remain within arms length to the patient. The rationale for 1:1 observation includes "actively suicidal/homicidal".

Interviews with PCT #1 on 8/2/16 at 10:00 AM and PCT #2 on 8/1/16 at 11:30 AM indicated they had completed observation flowsheets for Patient #1, however, the clinical record failed to include a 1:1 constant observation flowsheet per policy, which is used for identifying a patient's safety observation status and documenting that monitoring was provided. In addition, there was no other documentation in the clinical record of the 1:1 observation monitoring.

Interview with the Director of Patient Safety and Regulatory on 7/29/16 at approximately 3:00 PM identified that there were no 1:1 constant observation flowsheets for Patient #1 for 7/15/16 or 7/16/16.

Interview with RN #1 on 8/1/16 at 2:00 PM identified that on 7/16/16 it was reported to her that Patient #1 was suicidal, admitted due to a drug overdose and that Patient #1's observation status was to be 1:1. RN #1 isentified that he/she was aware that there was only one sitter available to observe Patient #1 and the roommate. RN #1 identified that he/she was in Patient #1's room with PCT #1 at the time of the incident.



2. Interview with PCT #3 on 7/29/16 at 2:10 PM identified that he/she was assigned and acting as a sitter to Patient #2 for 1:1 observation at that time. Upon surveyor inquiry regarding the difference between constant observation and 1:1 observations, PCT #3 stated that he/she didn't think there was a difference because both required full vision all the time. PCT #3 did not identify that 1:1 observations required the sitter to be within arms length of the patient.



3. Based on review of the clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 10 of 10 patients (Patients #1-#10) admitted to the hospital requiring suicide precautions and on 1:1 observation (arm's length), documentation and interviews failed to reflect that the 1:1 observations were implemented. The findings include:

Review of the clinical records for Patients #1-#10 and review of the hospital's Sitter Observation Log identified that each patient was admitted with suicide precautions and 1:1 observation. Although Observation Flowsheets were completed for part and/or all of the patients' hospitalization as per policy, the Flowsheets failed to differentiate between 1:1 and constant observation. Review of the Safety Observation Policy indicated that 1:1 observation was within arm's length for suicide precautions. Whereas, for constant observation, the patient was to be within view of the sitter. Review of the clinical records failed to reflect 1:1 observation (arm's length) was implemented.
Interviews with the Chief Nursing Officer and the Director of Patient Safety on 8/2/16 at 2:00 PM failed to identify that the 1:1 observations were implemented for Patients #1-#10.