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Based on observation, document review and interview it was determined that for 1 of 1 patients (Pt. #1) on suicide precautions, whose death subsequently followed, the Hospital failed to ensure the Behavioral Health Unit patients were safe from ligature risks, thus placing all patients with suicide ideation at serious and immediate risk for harm. As a result the Condition of Participation (42 CFR 482.13) Patient Rights was not in compliance. This potentially affects all current and future Behavioral Health Unit Patients.

Findings include:

1. The Hospital failed to provide sufficient safety measures to help prevent suicide. (A 144-A)

2. The Hospital failed to ensure the Behavioral Health Unit (BHU) had no ligature and environmental risks. (A 144-B)

3. The Hospital failed to ensure that staff were educated regarding: ligature risks, increased and decreased suicide risks, and levels of suicide intervention. (A 144-C)

4. The Hospital failed to ensure restraint orders were renewed at least every 4 hours, as required. (A171)


An immediate jeopardy began on 6/23/18 when the patient (Pt. #1) presented to the Emergency Department (ED) with suicidal ideation and was placed on a 1:1 (staff at arm's length from the patient) monitoring while in the ED. Pt. #1 was admitted to the Behavioral Health Unit on 6/23/18 at 4:55 PM and placed on every 15 minute safety observation monitoring. On 6/23/18 at 9:15 PM, Pt. #1 was found with a shower curtain tied around his neck slumped, cyanotic (blue) and transferred to ICU (Intensive Care Unit), where Pt. #1 subsequently died.

An immediate jeopardy was identified on 6/27/18 for the Hospital's failure to correct identified ligature risks, thus placing all psychiatric patients, on the Behavioral Health Unit, at serious potential risk for harm.

An immediate jeopardy was announced on 6/27/18/18 at 2:25 PM, during a meeting with the President, Interim Chief Medical Officer Interim Chief Nursing Officer, Director of Nursing and Director of System Quality. The Hospital failed to evaluate the corrective actions. The immediate jeopardy was not removed by the survey exit date of 6/28/18.

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) with suicide ideation and a plan, where a death followed, the Hospital failed to provide sufficient safety measures to prevent suicide.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 6/26/18. Pt #1 was a 60 year old male, who presented in the Emergency Department with a chief complaint of suicidal ideation. The Emergency Department (ED) history and physical (H & P) indicated, "Patient with severe depression for sometime. Last admitted about a month ago at ... (another hospital) for severe depression and suicidal ideation. Today patient's brother-in-law arrived to take the patient to Washington DC for a change of scenery since the patient is still been significantly depressed and the patient wandered off this morning. The brother-in-law found goodbye notes and goodbye photos. Patient was planning to jump off a building ... Patient admits that his plan today was to jump off a building ..." The patient was placed on 1:1 monitoring (staff at arms length from the patient) in the ED.

Pt. #1 was transferred to the Behavioral Health Unit (BHU) at 4:50 PM. The admission profile assessment completed on 6/23/18 at 5:09 PM, included a "Suicide Risk Scale" with a total risk score of 13. The profile included the following "Suicide/Self Harm Risk" question and answers: "What do you envision happening if you actually killed yourself? Answer-Escape; Have you made plans to harm or kill yourself? Answer -yes; Have you ever attempted suicide or engaged in self-damaging actions? Answer-yes (at another hospital)."

On 6/23/18, a house physician documented the following: "Code Blue (medical emergency) Activated at 9:29... He was found with a yellow sheet around his neck tied to the bathroom door; ACLS (advanced cardiac life support) started. At around 9:15 PM, staff ... made his round and saw patient on the bed. At 9:25 PM, while doing his q (every) 15 rounds, he saw the patient hanging from the bathroom door, with yellow sheet around his neck. He was unresponsive and cyanotic (blue). Code blue (medical emergency) was activated at once ...Patient was transferred to ICU." Pt. #1 was pronounced dead on 06/24/18 at 11:15 AM.

2. The Hospital's policy titled, "Therapeutic levels of Observation and Safety" (rev 2/2017), required, "CVO (Continuous Visual Observation) 1. Indication: a CVO is required when clinical assessment indicates that, although the patient is not, at the moment, actively seeking means and opportunity to engage in high risk behavior (moderate suicidal ideation...) the patient is assessed as high risk for such behavior... the patient would therefore require Continuous Visual Monitoring and must remain in the staff member's line of sight at all times.... A. CVO is initiated by a physician's order. B. The R.N. may initiate the CVO while attempting to contact the physician..."

3. The On 6/26/18 at approximately 2:40 PM the RN (Registered Nurse-E #2) was interviewed. E #2 stated that she conducted the BHU admission assessment on Pt. #1. E #2 stated, "I gave him (Attending Psychiatrist) the information about his previous suicide attempt, potential securities fraud and going to jail and he (patient) reported Seroquel to help him sleep." E #2 stated suicide precaution and every 15 minute observation were ordered by the physician. E #2 stated, "Every 15 minute safety observation means you have visual observation, their location, the time and the behavior." Regarding the details of suicide precautions, E #2 did not specify behaviors to watch and stated, "We still keep an eye on them because you can't predict the behavior. I don't know what behavior I'm looking for." Regarding the Suicide Risk Scale and Pt. #1's score of 13, E #2 stated, "I do not know how to interpret those numbers, I don't know what 13 means. It has not been brought to my attention what the score means. No warning system pops up (in the electronic medical record)." E #2 also stated that she had not received any training on scoring the risk assessment.

4. The Attending Psychiatrist (MD #1) was interviewed on 6/26/18 at approximately 4:00 PM. MD #1 stated that the patient was reported to him as "calm, participated with the intake and contracted for safety." MD #1 stated, "The presentation I got from the floor report was just of a patient of an average risk. You trust the information you get ... I would have put him on a line of sight (continuous visual observation) had I known he [Pt. #1] was found with notes, found with pictures, had a change of behavior and affect (mood) from the emergency room to the unit. If I had more information, he [Pt #1] would have been kept in a higher level of observation and I would have kept him in the hallway for the night for visual observation." MD #1 stated that he only received a report of the patient from the nurse, and had not interviewed or assessed the patient. MD #1 stated, "The doors should not have been able to support his [Pt. #1's] weight."

5. The Director of Quality (E #3), interviewed on 6/26/18 at 10:30 AM, indicated that the ligature assessment was conducted in January 2018 and February 2018. The assessment was presented and identified the entry doors to the rooms and bathroom doors (20 rooms with 2 doors for each room) as ligature points and a capital budget has been approved for mitigation.

6. The action plan resulting from the incident with Pt. #1's suicide included: development of a handoff policy specific to the Behavioral Health unit; continuation of level of observations from the ED to the BHU (Behavioral Health Unit), and the ligature mitigation to be completed by 8/31/18. However, the Hospital's action plan failed to include interim safety measures while the ligature mitigation is in process.



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B. Based on document review, observation and interview, it was determined that the Hospital failed to ensure the Behavioral Health Unit (BHU) had no ligature and environmental risks. These risks potentially could cause injury or death to 1 suicidal Patient (Pt. #2) on the BHU census on 6/26/18.

Findings Include:

1. On 6/26/18 at 12:00 PM, the Hospital's policy titled, "Contraband - Behavioral Health Unit" (revised 3/2016) was reviewed. The policy included, "H. Items that are restricted from the unit for the duration of the hospitalization... 1. Belts and suspenders, 2. Glass and sharp objects... 5 Long, string ties... 13. Items that contains long straps... I. Items that may be used with staff supervision only... Electrical appliances or self-care items which have a cord..."

2. On 6/26/18 from approximately 9:30 AM - 11:20 AM, an observational tour of the BHU was conducted. One of 13 patients (Pt. #2) was on Suicide Precautions. The following ligature risks and environmental hazards were observed:

- All patient entry room doors and bathroom doors included ligature risks - solid hinges attached to the door frame and solid door. The hinges present the structure to attach linen, cords, or other means of strangulation.

- An approximately 6 foot electrical cord attached to an organ in the dining room.

- A call bell was on a bed in room 634. The rounded edge of the bell was a thin solid metal which could potentially be used as a cutting device.

3. On 6/26/18 at 9:40 AM, an interview was conducted with the BHU Manager (E #5) during the BHU tour. E #5 stated that the Hospital has reviewed the door ligature risks and is working on a solution. The organ cord was not considered as a ligature risk and the call bell in room 634 is used by a patient who needs assistance.


C. Based on interview and document review, it was determined that for 5 of 5 sampled Behavior Health Unit (BHU) employees (E #1, 2, 3, 7, & 8) reviewed for management of suicidal patients, the Hospital failed to ensure that training included: ligature risks, suicide levels of intervention, and factors that decrease suicide risks.

Findings include:

1. On 6/27/18, a policy for BHU staff education was requested. On 6/28/18 at approximately 9:30 AM, an interview was conducted with the Director of Systems and Quality (E #3). E #3 stated that BHU staff receive training related to all BHU issues but there is no policy regarding BHU staff education.

2. On 6/27/18 at 11:20 AM, 5 BHU employee files were reviewed (3 Registered Nurse files - E #2, E #3, E #8, and 2 Mental Health Counselors - E #1 and E #7). All 5 employee files lacked documentation of ligature risk training, levels of suicide intervention, and factors to decrease suicide risk.

3. On 6/27/18 at 3:00 PM, an interview was conducted with the Director of the Behavioral Health Unit (E #9). E #9 stated that BHU staff training for ligature risks, suicide levels of intervention, and factors that decrease suicide risk has not been presented in education sessions.

A. Based on document review and interview, it was determined, that for 1 of 3 clinical records (Pt. #4) of restrained patients, the Hospital failed to ensure restraint orders were renewed at least every 4 hours, as required.

Findings include:

1. On 6/26/18 at 1:30 PM, the Hospital's policy titled, "Utilization of Restraints and Seclusion" (revised 7/13/17) was reviewed. The policy required, "V. Required Procedures: B. Restraint and Seclusion for Violent and Self Destructive Behavior... 3. Order Review and Renewal for Violent and Self-Destructive Behavior. a. Restraint orders for Violent and Self-Destructive Behavior and Seclusion may be renewed for up to 24 hours in the following increments: i. 4 hours for adults 18 years of age or older..."

2. On 6/26/18 at 10:35 AM, the Behavioral Health Unit's Restraint Log was reviewed. One Patient (Pt. #4) was included in the Log 13 times between 6/20/18 and 6/22/18.

3. On 2/26/18 at 10:40 AM, Pt. #4's clinical record was reviewed. Pt. #4 was a 31 year old male, admitted on 6/20/18, with diagnoses of severe psychosis, and rule out delirium. Pt. #4 had a physician's order dated 6/20/18 at 7:59 PM, for bilateral wrist and ankle restraints, for up to 4 hours, due to "danger to other." Pt. #4's "Notice Regarding Restricted Rights of Individuals" dated 6/20/18 at 7:59 PM, included, "Patient physically aggressive, throwing items, threatening staff..." Subsequent physician's orders and progress notes included Pt. #4's restraint orders were renewed many times, up to and including 6/22/18 at 6:47 PM. During this time period, there were 2 occassions when the restraint renewal orders exceeded 4 hours:

- 6/21/18 between 7:33 AM and 12:38 PM, 5 hours and 5 minutes.
- 6/22/18 between 7:12 AM and 12:22 PM, 5 hours and 10 minutes.

4. On 6/27/18 at 10:00 AM, an interview was conducted with the Manager of BHU (E #5). E #5 stated that the physician should have been called within 4 hours to renew the restraint order.